Columbia  ©ntbersittp    \ 

tntfjeCttpof  J2eto§orfe  e^ 

COLLEGE  OF  PHYSICIANS 
AND   SURGEONS 


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THE  AFTER-TREATMENT 
OF  SURGICAL  PATIENTS 

VOL.  I 


THE  AFTER-TREATMENT 

OF 

SURGICAL  PATIENTS 


BY 

"WILLARD  BARTLETT,  A.M.,  M.D.,  F.A.C.S. 

AND 

COLLABORATORS 


VOL.  I 


WITH  TWO  HUNDRED   TWENTY-TWO   ORIGINAL 
ILLUSTRATIONS  AND  ONE  COLOR  PLATE 


ST.  LOUIS, 

C.  V.  MOSBY  COMPANY 

1920 


Copyeight,   L920,   By  C.  V.  Mosby  Company 

(All  rights  reserved) 


Press  of 

C.    V.    Mosby    Company 

St.   Louis 


TO 
THE  MEMORY  OF  MY  FATHER 
AUBELIUS  TWOMBLEY  BABTLETT,  M.D. 

"WHO  EVER  CHOSE  THE  HARDEE  WAY, 

WHICH  IS  THE  PATH 

THAT  CAN  BE  TRODDEX  ONLY 

BY  THE  FOOT  OF  A  MAX" 

(Farnol) 


PREFACE 

Fortunately,  every  mammalian  entity  is  a  machine  highly  en- 
dowed with  possibilities  of  automatic  adjustment  and  repair. 
Among  the  lower  animals,  those  that  are  wild  must  depend  upon 
themselves  during  the  period  of  repair  that  follows  an  injury 
which  is  not  immediately  fatal.  Our  domestic  animals,  more 
fortunately  situated,  do  experience  a  certain  amount  of  external 
aid  in  similar  times  of  distress,  while  man  is  practically  never  with- 
out sympathetic,  and  in  many  instances,  scientifically  directed  care, 
whenever  he  experiences  any  deviation  from  the  normal  physiologic 
tenor  of  his  existence. 

Always  granting  a  correct  diagnosis,  promptly  established  op- 
erative indications,  and  well  appraised  pathologic  conditions  amena- 
ble to  surgical  treatment,  it  is  true,  in  the  majority  of  instances, 
that  the  need  of  after-treatment  is  in  inverse  proportion  to  the 
quality  of  work  done  on  the  operating  table.  Be  this  as  it  may,  some 
of  our  patients  do  perfectly  well  if  let  alone,  while  many  of  them 
are  made  much  more  comfortable  by  properly  directed  after-care, 
and  a  few  are  certainly  lost  for  the  lack  of  it. 

In  this  volume,  in  most  instances,  the  consideration  of  surgical 
technic  has  been  omitted ;  however,  instances  will  arise  in  which 
mention  of  certain  operative  details  must  be  made,  in  order  that 
the  therapeutic  suggestions  may  be  completely  understood.  Sur- 
gical after-treatment  has  been  considered  as  beginning  when  the 
last  suture  is  tied,  and  lasting  until  the  patient  is  restored  to  normal 
health.  My  follow-up  system,  to  which  attention  has  been  called 
elsewhere  in  this  work,  contemplates  a  correspondence  with  every 
patient  for  at  least  one  year  following  the  operation,  but  one  can 
imagine  a  much  more  lengthy  course  of  after-treatment  in  certain 
individuals,  e.  g.,  those  who  are  compelled  to  live  within  definite 
limits  after  such  operations  as  are  performed  for  the  cure  of  pyloric 
ulcer. 

Such  a  work  naturally  divides  itself  into  two  parts:  one  which 
has  to  do  with  general  subjects,  and  the  other,  with  the  measures 
of  after-treatment  as  they  are  applied  following  operations  upon 
the  various  organs.  One  must  place  some  practical  limit  upon  the 
scope  of  such  a  work,  hence,  no  consideration  has  been  given  to 


X  PREFACE 

the  postoperative  consequences  and  the  treatment  of  some  extremely 
rare  procedures,  especially  those  handled  by  the  sharply  restricted 
specialists.  However,  it  was  thought  well  to  give  detailed  atten- 
tion to  many  of  the  procedures  from  special  fields,  which  may  at 
times  confront  the  worker  in  general  medicine  or  surgery. 

It  is  hoped  that  this  book  will  make  an  appeal  to  those  who,  like 
myself,  have  at  times  desired  this  subject  treated  more  in  detail 
than  is  possible  in  the  excellent  works  on  general  surgery  a1  our 
command. 

If  originality  seems  to  have  been  claimed  for  any  of  the  methods 
herein  advocated,  or  even  for  the  form  in  which  they  are  presented, 
it  is  done  with  full  knowledge  that  "there  is  nothing  new  under  the 
sun"  in  the  field  of  medicine,  and  in  the  hope  that  faulty  informa- 
tion may  not  often  prevent  giving  credit  for  priority  when  it  is 
due. 

The  procedures  which  my  collaborators  and  I  recommend  have 
practically  all  proved  their  worth  in  an  extensive  personal  ex- 
perience, still,  Ave  all  have,  as  will  be  noted,  drawn  freely  and 
impartially  from  the  Literature,  striving  always  to  be  scrupulously 
fail-  in  acknowledging  our  indebtedness  to  others.  It  is  no  less  a 
pleasure  than  a  duty  to  emphasize  in  a  general  way  this  obligation 
on  our  part  it'  anywhere  we  may  have  seemed  remiss. 

Dr.  0.  F.  McKittrick's  chapters  speak  for  themselves;  still  it 
is  with  the  utmost  satisfaction  that  T  here  accord  him  unstinted 
praise  and  appreciation  for  his  untiring  efforts  while  he,  as  my  house 
surgeon,  collected  many  of  the  clinical  data  on  which  this  work  is 
based. 

Not  only  am  I  fortunate,  hut  the  reader  as  well,  thai  eleven  of 
the  chapters  have  beeu  most  graciously  contributed  by  men  who 
are  especially  qualified  to  handle  i  he  subjects  in  question.  Their 
names  appear  under  the  titles  of  their  respective  chapters.  In  ad- 
dition to  these  writers,  I  desire  to  thank  Doctors  William  .1.  .Mayo. 
Charles  II.  .Mayo.  George  W.  Crile,  Stuart  McGuire,  and  Joseph 
Bloodgood  \'<>v  inspiration  and  assistance  which  has  been  invalua- 
ble. 

Dr.  S.  I-1.  Weiinerinan  kindly  corrected  the  manuscript  of  many 
chapters  and  \)v.  I-\  K.  Ilensel  proved  a  painstaking,  faithful  co- 
worker in   helping  place  the  numerous  illustrations. 

WlLLARD    BARTLETT. 

St.  Louis,   Mo. 


CONTENTS 
VOL.  I 

CHAPTER  I 
The  Ideal  Postoperative  Room   (By  0.  F.  McKittrick) 1 

CHAPTER  II 
Records  and  Charts   (By  Willard  Bartlett) - .     .        7 

CHAPTER  III 

Preliminary  Considerations  and  Anesthesia  (By  O.  F.  McKittrick)     .       15 

CHAPTER  IV 
Prom  Table  to  Bed    (By  O.   F.   McKittrick) 23 

CHAPTER  V 

Immediate  Effects  of  Anesthesia  and  Operation  (By  O.  F.  McKittrick)       27 

CHAPTER  VI 
Earliest  Subjective  Manifestations  (By  0.  F.  McKittrick)     ....       36 
Pain,  36;   Thirst,  39;   Nausea  and  Vomiting,  40;   Dreams,  45;   Mental 
Aberrations,  45;  Complications  Arising  After  Local  Anesthesia,  46. 

CHAPTER  VII 

Later  Subjective  Symptoms   (By  Willard  Bartlett) 49 

Ether  Conjunctivitis,  49;  Dry  Mouth,  50;  Painful  Tongue,  51;  Sore 
Ja-'.v,  52 ;  Sore  Throat,  53 ;  Painful  Respiration,  54 ;  Anesthesia  Paral- 
ysis, 55. 

CHAPTER  VIII 
Sleeplessness    (By   O.    F.    McKittrick) 61 

CHAPTER  IX 
Hiccough    (By  O.   F.   McKittrick) 68 

CHAPTER  X 
Headache    (By  O.   F.   McKittrick) 74 

CHAPTER  XI 
Backache    (By  0.   F.  McKittrick) 82 


Xll  CONTEXTS 

CHAPTER  XII 
Shock    (By    Willard    Rartlett) 91 

CHAPTER  XIII 
Hemorrhage   (By  Willard  Bartlett) 103 

CHAPTER  XIV 

Dilatation  of  the  Heart  with  Reference  to  Postoperative  Acute  Dila- 
tation (By  Willard  Bartlett  and  Riley  M.  Waller)     .     .     .     .     113 
Pathology,   115;   Diagnosis,   116;    Treatment,   116;    Summary,   170. 

CHAPTER  XV 

A.CDTE  Dilatation  of  the  Stomach  (By  O.  P.  McKittrick) 118 

Symptoms,    L23;    Treatment,  124. 

CHAPTER  XVI 

PostopeFvATIye  Ileus   (By  Willard  Bartlett) 120 

Mortality,  120;  Pseudoileus,  120;  Symptoms,  127;  Prognosis.  127: 
Treatment,  127;  Classification  of  True  Ileus,  128;  Symptoms  and  Diag- 
nosis,  132;    Mechanism   and  Cause  of  Symptoms,   133. 

CHAPTER  XVII 
Fat  Embolism  | .  P.y  ().  F.  McKittrick) 139 

CHAPTER  XVIII 
Heat  Stroke   (By   O.   F.   McKittrick) 147 

CHAPTER  XIX 

Postoperative  Burns  I  By  Willard  Bartlett) 150 

Depilatory  Burns,  150;  Iodine  Burns,  150;  Ether  Burns,  151;  Hot-water 
Bottles,  151;  Enemas,  152;  The  Electric  Light,  152;  X-ray,  153;  Ice, 
154;  Pathology  and  Morbid  Anatomy,  151;  Symptoms,  150;  Frostbite, 
158;  Prognosis,  159;  Treatment,  159. 

CHAPTER  XX 
Bed  Sores   (By  O.  F.  McKittrick:) 104 

CHAPTER  XXI 
Postoperative  Prolapse  op  Abdominal  Viscera  (By  Willard  Bartlett)     170 

CHAPTER  XXII 
Foreign  Bodies  Lost  in  the  Peritoneal  Cavity  (By  Willard  Bartlett)     175 

CHAPTER  XX] II 

Fistula    (By    Willard    Bartlett) 187 

Treatment,    187;   Digestive  Tract,   188;   Intestine,    189;    Complications, 

191;    Other    Varieties   ot'    Postoperative    Fistula1,    194. 


CONTEXTS  X1H 

CHAPTER  XXIV 
Sinuses   (By  O.  F.  McKittrick) 199 

CHAPTER  XXAT 
Drug  Addiction  in  Surgical  Patients  (By  0.  F.  McKittrick)     ....     204 

CHAPTER  XXVI 

Alcoholism  in  Its  Relation  to  Surgery  (By'  0.  F.  McKittrick)     .     .     .     211 
Delirium  Tremens,  212. 

CHAPTER  XXVII 

Postoferatve  Psychoses    (By  0.   F.   McKittrick) 217 

Febrile  Delirium,  225;  Delirium  Nervosum,  226;  Senile  Delirium,  227; 
Hysterical  Delirium,  227. 

CHAPTER  XXVIII 
Acid  Intoxication   (By-  0.  F.  McKittrick) 232 

CHAPTER  XXIX 
Dlabetes  in  Surgery  (By  0.  F.  McKittrick) 239 

CHAPTER  XXX 
Nephritis,  Anuria,  and  Uremic  Coma  Following  Anesthesia  (By  O.  F. 

McKittrick)       247 

CHAPTER  XXXI 
Bactefjemia  (General  Septic  Infection)   (By  O.  F.  McKittrick)     .     .     .     255 
Symptoms,  258;   Treatment,  259. 

CHAPTER  XXXII 
Postoperative  Tetanus   (By-  O.  F.  McKittrick) 261 

Treatment,  266. 

CHAPTER  XXXIII 
Gas  Bacillus  Infection  (By  O.  F.  McKittrick) 269 

CHAPTER  XXXIA' 

Postoperative  Pneumonia  (By-  0.  F.  McKittrick) 273 

Symptoms,  277;   Treatment,  27S;   Pleurisy,  284. 

CHAPTER  XXXV 
Parotitis    (By-  O.   F.   McKittrick) 2S7 

Symptoms,  289;  Treatment,  291. 

CHAPTER  XXXVI 
Subdiaphragmatic  Empyema  (Localized).     (By  O.  F.  McKittrick)     .     .     294 
Symptoms,  296;   Treatment,  297. 


XIV  CONTENTS 

CHAPTER  XXXYII 

Thrombophlebitis    (By  O.  F.  McKittrick) 300 

Symptoms,  303;  Treatment,  305. 

CHAPTER  XXXVIII 

Pulmonary   Embolism    (By  "Willard   Bartlett) 309 

Anatomy,  310;  Pathogenesis,  311*  Symptoms,  315;  Treatment,  317. 

CHAPTER  XXXI X 

Pylephlebitis    (By    O.    F.    McKittrick) 319 

Treatment,  321. 

CHAPTER  XL 

Skin  Eruptions   (By  O.  F.  McKittrick) 325 

Ether  Rash,  326;  Septic  Rash,  326;  Erysipelas,  331. 

CHAPTER  XLI 

Hemophilia  and  Other  Hemorrhagic  Diseases  (By  O.  F.  McKittrick)  333 

Treatment,  336. 

CHAPTER  XLI  I 
Artificial  Respiration  (By  Willard  Bartlett  and  Adolph  Rumreich)     .     343 
Manual  Methods  of  Artificial  Respiration,  343;  Howard's  Method,  343; 
Silvester's  Method,   344;    Brosch's  Modification  of  Silvester's  Method, 
344;  Silvester-Howard  Method,  345;   Schafer's  Prone-Pressure  Method, 
346;  Artificial  Respiration  with  Apparatus,  347;  Pulmotor,  347;  Lung- 
motor,   347:    Meltzer's  Pharyngeal   Insufflation  Apparatus,    347;    Intra 
laryngeal    Insufflation,    348;    Intratracheal    Insufflation    of    Meltzer   and 
Auer,  348;   Laborde's  Tongue  Traction,  349;   Stimulation  of  the  Circu- 
lation,  349;    Heart    Massage,   350;   Indirect   or   Intrathoracic  Massage, 
350;  Direct  or  Intrathoracic  Massage,  350;  Respiratory  Stimulation  by 
Sodium  Cyanide,  350;  Electricity,  350;   Adrenalin,  350;  Oxygen  Inhala- 
tion, 350;  Position,  350. 

<  IIAPTER  XLIII 
Postoperative  Feeding   (By  .1.  W.  Larimore) 352 

CHAPTER  XLIY 
Reduction  of  Obesity  (By  Willard  Bartlett  and  Alfred  Goldman)     .     3,62 
Diet,  363;   Mechanical  Treatment,  366;   Medicinal  Treatment,  367. 

CHAPTER  XLV 
Artificial  Nutrition  (By  Willard  Bartlett  and  M.  G.  Peterman)     .    .    369 
Nutrition    Per    Rectum,    370;    Gastrostomy,    374;    Finney's    Diet,    377; 
Leube's  Diet,  as  Modified  by  Lockwood,  .".77;  Jejunostomy,  378;   Intra 
venous,  378;  Subcutaneous,  .",79;  Intraperitoneal,  381  ;  Cutaneous  Appli- 
cation, 382. 


CONTEXTS  XV 

CHAPTER  XLVI 
Cake  of  the  Bowels  After  Operatiox  Other  Than  Gastrointestinal 

(By  Willard  Bartlett)     . 383 

Constipation,    383;    Prophylaxis,    386;     Diarrhea,  389. 

CHAPTEE  XL  VII 
Treatment  of  Postoperative  Eetextiox  of  Urine  and  Cystitis  (By  Johx 

E.    Caulk) 392 

Effects  of  Anesthesia,  392 ;  Treatment,  393 ;  Catheterization  of  the  Male, 
394;  Treatment  of  Postoperative  Cystitis,  396;  Symptoms,  397;  Treat- 
ment, 398;  Medical  Treatment,  398;  Local  Treatment,  400. 

CHAPTEE  XLVlII 

The  Treatment  of  Wounds   (By  Willard  Bartlett) 402 

Historical  Considerations,  402 ;  Principles  "Which  Underlie  Wound  Heal- 
ing, 402;  Early  Treatment  of  Aseptic  or  Closed  Wounds,  406;  Early 
Treatment  of  Infected  or  Open  Wounds,  410;  Dakin's  Fluid,  415;  For- 
eign Substances,  431 ;  Some  Eemote  Consequences  of  Wounds,  432 ;  Late 
Treatment  of  Wounds,  433.    - 

CHAPTEE  XLIX 

Bandaging  (By  O.  F.  McKitteick) 440 

Head  Bandages,  443;  Xeck  Bandages,  448;  T -bandages,  461;  Suspens- 
ory bandages,  461. 

'  CHAPTEE  L 
The  Abdominal  Binder.     (By  O.  F.  McKittrick) 475 

CHAPTEE  LI 

Exercise  and  Massage    (By  F.  H.  Ewerhardt) 483 

Massage,  484;  General  Discussion,  4S4;  Physiologic  Effect,  485;  Tech- 
nic,  487;  Vibration,  495;  Portable  Apparatus,  496;  Stationary  Appar- 
atus, 496;  Shaking  and  Kneading  Appliances,  496; Physiologic  Effect, 
496;  Exercise,  497;  Physiologic  Effect  of  Exercise,  499;  General  Out- 
line of  Exercise  Treatment  for  the  More  Common  Indications,  500; 
Special  Exercises  for  Strengthening  the  Heart,  504;  Hernia,  506;  Flat 
Feet,  508;  Joint  Disturbances,  511;  Early  Functional  Treatment  of 
Fractures,   513;   Paralysis,   515. 

CHAPTEE  LII 

Hydrotherapy  (By  F.  H.  Ewerhardt) 519 

Reflex  Effects,  520;  Special  Reflex  of  Prolonged  Cold,  520;  Special  Re- 
flex Effect  of  Short  Cold,  520;  Special  Reflex  Effects  of  Hot  Appli- 
cations, 521;  Hydrostatic  Effects,  521;  Technie,  523;  Fomentation, 
523;  Heating  Compresses,  524;  Ice  Pack,  524;  Cold  Wet  Pack,  525; 
Hot  Wet  Pack,  525;  Hip  or  Sitz  Bath,  526;  Cold  Sitz  Bath,  526;  Pro- 
longed Cold  Sitz  Bath,  527;  Salt  Glow,  527;  Xauheim  Baths,  528;  Grad- 
uated Tonic  Cold  Applications,  530;  Cold  Mitten  Friction,  530;  The 
Wet  Sheet,  or  Sheet  Bath,  530;  Shallow  Bath,  531;  Cold  Douche,  531; 
Alternating  Hot  and  Cold  Douches,  532 ;  The  Electric  Cabinet  Bath,  532. 


XVI  CONTENTS 

CHAPTER  LIII 

Postoperative  Treatment  by  Radium  and  the  Roentgen  Rays  in  Ma- 
lignancy (By  Russell  H.  Boggs) 535 

Carcinoma  of  the  Breast,  536;  Carcinoma  of  the  Uterus,  545;  Carcinoma 
of  the  Rectum,  550 ;  Epithelioma,  552 ;  Cancer  of  the  Mouth  and  Throat, 
559;  Sarcoma,  562. 

CHAPTER  LIV 

Reamputations  (By  Willard  Bartlett  and  Walter  S.  Priest)  ....  564 
Osteoplastic  Reamputation,  565 ;  Other  Methods  of  Reamputation,  569 ; 
Flapless  Method  of  Reamputation,  571 ;  Apparent  Lengthening  of  an 
Arm  Stump,  572;  Kineplastic  Reamputations,  572;  Single  Motor  Flap 
in  Amputation  Through  the  Arm,  574;  Double  Motor  Flap  in  Amputa- 
tion Through  the  Forearm,  574;  Amputation  of  Forearm  Providing  a 
Plastic  Club  Motor,  575. 

CHAPTER  LV 
Proctoclysis  (By  O.  F.  McKittrick) 577 ^ 

CHAPTER  LVI 
Hypodermoclysis    (By   Willard   Bartlett) 586 

CHAPTER  LVII 

Blood   Transfusion    (By  Willard   Bartlett) 596 

Technic,  599;   The  Selection  of  Donors  for  Transfusion,  624. 

CHAPTER  LVI  1 1 
The  Reconstruction  of  the  Patient  (By  Robert  S.  Carroll)     ....     630 
The  Nutritional   Reeducation,  631;   The  Mental  Readjustment,  634. 

CHAPTER  LIX 
Postoperative  Treatment  in  Children  (By  Willard  Bartlett  and  J.  B. 

Carlisle) 638 

CHAPTER  LX 
Postoperative  Treatment  in  Old  Age  (By  Willard  Bartlett  and  C.  R. 

Fancher) 647 

CHAPTER  LXI 
Symptoms  and  Signs  ok  Impending  Death   (By  O.  F.  McKittrick)     .     .     656 
Sudden  Death,  659. 

CHAPTER  LX  1 1 

Postoperative  .Mortality  (By  Willard  Bartlett  and  P..  L.  Adelsberger)     664 


ILLUSTRATIONS 

FIG.  PAGE 

1.  Ground  plan  of  postoperative  room,  anteroom,  and  sun  parlor     ....  2 

2.  An  antislamming  device  used  at  the  Mayo  Clinic 3 

3.  An  iron  bedstead  used  at  the  Mayo   Clinic 4 

4.  The  ideal  bed  showing  the  mattress  and  the  arrangement  of  bed  clothes 

for  the  immediate  reception  of  an  unconscious  postoperative  patient  4 

5.  Pillows  and  rubber  slips 5 

6.  A  headrest  built  in 5 

7.  Eecord  of  patient's  condition,   findings,   and  operation     ......  8 

8.  Postoperative  orders 9 

9.  Chart   for    eight    observations    daily 10 

10.  Admission    and    treatment    chart 11 

11.  Clinical    postoperative    laboratory    record 12 

12.  Record  of  posthospital  examinations  of  simple  nature 13 

13.  Position  of  patient  on  operating  table  showing  restraining  strap  across 

lower  limbs 20 

14.  A  mask  used  for  administration  of  gas  and  ether  combined 21 

15.  A  convenient  way  of  transferring  the  patient  from  the  operating  room 

to  the  stretcher  or  ward  carriage 24 

16.  Ward  carriage  ready  to  receive  patient  from  operating  table     ....  25 

17-A.  Patient  just  returned  from  the  operation 26 

17-B.  Position  of  patient  prior  to  being  lifted  into  bed 26 

18.  A  convenient  method  of  washing  an  eye  which  has  been  irritated  during 

anesthesia        33 

19.  A  convenient  scheme  for  the  early  administration  of  fluids 41 

20.  Patient's   head   is  lowered   in   order   that   blood  may   gravitate   to   the 

cerebral  centers  and  the  heart 101 

21-A.  The  simplest  means  of  increasing  the  amount  of  blood  in  the  heart 

and   central  nervous   system Ill 

21-B.  A  posture  suggested  for  shock  and  hemorrhage  where  the  respiratory 

apparatus   is   full   of   mucus Ill 

22.  Fat  embolism  of  lung  following  multiple  fractures 140 

23.  Skin  grafts  on  an  extensive  burn  surface  (Color  Plate) 160 

24.  Wire  cage  to  protect  skin  grafts  on  burn  surface 161 

25.  Bedsores  following  myelitis 165 

26.  Healed   bedsores        165 

27.  Eusty  forceps  removed  from  abdomen  at  a  remote  period ISO 

28.  A  method  of  confining  the  hands  used  at  the  Minnesota  State  Hospital, 

Eochester 221 

29-A.  A  simple  method  of  tying  the  feet,  which  allows  the  patient  to  sit  up 

in  bed 222 

29-B.  A  useful  leg  cuff  and  strap  which  permits  patient  to  sit  up  in  bed     .  222 

30.  Method  of  forcing  the  mouth  open  for  the  purpose  of  forced  feeding     .  223 

xvii 


Xviii  ILLUSTRATIONS 

FIG.  PAGE 

31.  Showing  the  probe  passing  behind  the  last  molar  tooth  and  tickling  the 

fauces,  thereby  causing  immediate  opening  of  the  mouth     .     .     .  224 

32.  Showing  round  soft  pine  stick  tied  in  position  between  the  teeth     .     .     .  225 

33.  A  simple   scheme  for  restraining  hands  and  feet   only 228 

34.  Method  of  restraining  the  body  by  means  of  a  sheet 229 

35.  Straight  jacket  with  comfortable  hand  arrangement  for  walking  insane 

patients 230 

36.  Straight  jacket  as  shown  in  Fig.  35  combined  with  confining  sheet     .     .  230 

37.  The  tetanus   bacillus       262 

38.  Opisthotonus 266 

39.  Applying  alcohol  to  the  cup 280 

40.  Igniting   the    alcohol        281 

41.  Three  cups  in  place 282 

12.  Gauze  moistened  in  equal  parts  of  glycerin  and  water  to  prevent  the  open 

mouth   from   drying 291 

43.  Wrapping  the  leg  in  common  cotton  batting 304 

44.  The  leg  elevated  and  splinted  on  a  pillow 305 

45.  The  extremity  protected  from  the  bed  covers,  and  a  hot-water  bottle  ap- 

plied to  the  sole  of  the  foot 306 

46.  Complete  blocking  of  pulmonary  artery  by  embolus 310 

47.  Pulmonary  emboli  removed  at  autopsy 311 

48-A.  Tributaries  of  the  portal   vein 320 

48-B.  The  portal  vein 321 

49.  Apparatus  used  by  Welch  for  collecting  blood  serum 340 

50.  First  act  in  the  Sylvester  method 345 

51.  Second  act  in  the  Sylvester  method 345 

52.  A  convenient  scheme  for  early  administration  of  fluids 353 

53.  The  introduction  of  liquid  food  directly  into  the  stomach 375 

54.  Patient  first  ensalivates  his  food  and  then  sends  it  indirectly  into  his 

own    stomach 376 

55.  A  convenient  wire  basket  containing  the  necessary  materials  for  dressing 

wounds 406 

56.  Large  basket  containing  materials  used  in  treatment  of  wounds     .     .     .  407 

57.  A  water  bottle  which  may  be  maintained  at  any  temperature  by  means 

of  a  stream  of  water  passing  through  it 407 

58.  Stitch  pulled  up  and  cut  through  portion  that  was  buried  in  skin     .     .  408 

59.  Dividing  and  removing  superficial  stitches 409 

60.  Method  of  removing  stitch   from  beneath  rubber  cover  of  tension   suture  410 

61.  Cleaning  the  wound  after  stitches  have  been  removed 411 

62.  Acutely  inflamed  scrotum  and  penis  to  which  glycerin  pack  is  about  to 

be   applied 412 

63.  Same  scrotum   and   penis  after  twenty  four   hours'   application   of   glyc- 

erin   pack        412 

64.  First    step    in   making   cotton    pledgets 413 

65.  Second  step  in  making  cotton  pledgets 414 

66.  Third  step  in  making  cotton  pledgets 414 

67.  Small  covered  basins  for  holding  antiseptic  solutions 415 

68.  Washing  lip  of  alcohol  bottle  before  pouring  the  liquid  on  a  cotton  sponge  415 

69.  Use  of  ordinary  adhesive  for  holding  dressings  in  place 416 


ILLUSTRATIONS  XIX 

FIG.  PAGE 

70.  Attaching  gauze  tapes  to  adhesive 417 

71.  Gauze  tapes  tied  so  that  adhesive  does  not  have  to  be  pulled  off  skin 

when  changing  dressings 417 

72.  The  Carrel-Dakin  glass  distributor        419 

73.  The  injection  of  Beck's  bismuth  paste 422 

74.  A  convenient  cradle  under  which  a  large  surface  may  be  kept  exposed     .  423 

75.  A  small  shield  for  exposing  a  small  area 423 

76.  An  automatic  glass  rubber  cupping  device 424 

77.  A  positive   suction  cupping   device      . 425 

78.  A  convenient  way  of  storing  sterile  gauze  packing  in  glass  tubes     .     .     .  426 

79.  Granulations  covered  with  gutta  percha  which  protects  them  from  gauze 

dressings  which  would  otherwise  adhere 427 

80.  The  insertion  of  stitches  which  are  intended  to  hold  gauze  packing  in 

place      .      .      .      . 428 

81.  The   gauze  packing  held  in  place  by  tied  suture  end 429 

82.  Split  rubber  tube  drain  as  used  at  the  Mayo  Clinic 430 

83.  Fenestruni  in  a  plaster  cast  as  used  at  the  Mayo  Clinic 431 

84.  Injecting  local  anesthetic  under  skin  of  thigh  previous  to  cutting  grafts  432 

85.  Cutting  the  grafts  with  a  razor 433 

86.  Spreading  the  grafts  on  gutta  percha 434 

87.  Trimming  irregular  edges  of  graft  and  gutta  percha 434 

88.  Grafts  in  place  on  a  varicose  ulcer  of  the  ankle 435 

89.  Cross  layers  of  gutta  percha  which  fix  grafts  and  their  backing  in  place  435 

90.  Gauze  and  adhesive  which  covers  grafts  and  gutta  percha 436 

91.  Ordinary  gauze  bandage  which  covers  gauze  and  adhesive  left  on  forty- 

eight  hours 436 

92.  Eemoving  gutta  percha  after  grafts  have  remained  in  place  forty-eight 

hours .  437 

93.  Open  air  treatment  of  grafts  after  first  forty-eight  hours'  compression  437 

94.  An  attempt  to  cover  an  old  granulating  wound  with  a  bridge  of  skin     .  438 

95.  Autotransplantation   of    bone 438 

96  Method  of  cutting  a  roll  of  muslin  into  bandages     .         441 

97.  Boiling  a  bandage  by  hand 442 

98.  Bandage    scissors 442 

99.  A  head   roller   bandage 443 

100.  A    towel    folded    for    bandaging 444 

101.  First  step  of  applying  towel  bandage  to  head 444 

102.  The  completed  head  bandage,  eyes  and  ears  Included 445 

103.  The  completed  head  bandage,  eye   (or  eyes)   excluded 445 

104.  A   roller  bandage   applied  to   an   amputation   stump 446 

105.  Method  of  folding  towel  for  bandaging  face 446 

106.  First  step  of  face  bandage 447 

107.  Final  step  for  bandage  of  face  and  eye 447 

108.  Final  step  in  hood  bandage  for  sides  of  face  and  head 44S 

109.  Posterior   appearance    of   hood   bandage 44S 

110.  A  simple  dressing  with  gauze  support  for   goiters 449 

111.  A  high  neck  bandage  held  up  by  cardboard  inserts 450 

112.  Simple  neck  towel  bandage 451 


XX  ILLUSTRATIONS 

FIG.  PAGE 

113.  Neck   and  breast   bandage   as   viewed   from   behind 451 

114.  A  combination  neck  and  breast  towel  bandage 4-11 

115.  The  towel  folded  as  used  in  chest  bandages 452 

116.  A  towel   chest   bandage 452 

117.  Posterior  view  of  chest  bandage 452 

118.  Towel  chest  shoulder  bandage  held  in  place  by  strip  of  gauze     .     .     .  453 

119.  Chest  shoulder  bandage  as  shown  from  behind 453 

120.  Chest  towel  bandage  with  arm  included 453 

121.  Fig.    120    as    viewed    from    behind 45.°, 

122.  A  double  towel  bandage  for  chest  and   shoulder 454 

123.  Second   step   of   ehest   shoulder   bandage 454 

124.  Arm  held  in  position  by  accessory  fold  of  bandage  pinned  to  lower  edge  454 

125.  Beginning  step  in  shoulder  breast  bandage 454 

126.  First   stage   of   Velpeau 455 

127.  Second    stage    of    Velpeau 455 

128.  Third  stage  of   Velpeau 455 

129.  Fourth    stage    of    Velpeau 455 

130.  A  convenient  towel  bandage  for  one  upper  extremity 456 

131.  Gauze  sling  for  arm 456 

132.  Gauze  sling  as  viewed  from  side 456 

133.  The  sling  run  through  a  rubber  tube  to  protect   the  neck  from   pressure  457 

134.  A  towel  folded  for  purpose   of  bandaging  hand 45S 

135.  Second   step   in   towel   bandage  of   band 458 

136.  Pinal  step  of  towel  bandage  of  hand,  palmar  aspect 45s; 

137.  Final  step  of  towel  bandage  of  hand,  dorsal  aspect 15s. 

138.  First  step  of  towel  bandage  of  thigh 459 

139.  Second   step   of  towel  bandage   of  thigh 459 

140.  Towel  bandage  of  leg  and  thigh 459 

141.  First  step   of  towel  bandage  of   foot    ami    ankle 460 

1  111.   Second  step  of  towel  bandage  of  foot  and  ankle 460 

1  13.   Third  step  of  towel  bandage  of  foot  and  ankle 460 

144  Final  step  of  towel  bandage  of  foot  and  ankle 460 

1  15.  Single   T-bandage 161 

146.  Double-tailed  T-bandage 461 

147.  Pattingson  's  plaster  bandage  rolling  machine  viewed  from  the  side  .  463 
1  18.  Pattingson 's  plaster  bandage  rolling  machine,  viewed  from  above  .  .  463 
1  l;».  Pattingson's  scheme  for  wrapping  plaster  of  Paris  bandages  in  tissue 

paper 464 

150.  A   device  for  immersing  plaster  of   Paris   bandages 465 

151.  V  device  for  expressing  water  from  plaster  of  Paris  bandages     .     .     .  466 

152.  A  convenient  box  for  supporting  patient  during  application  of  plaster 

cast 467 

153.  Tricot  and  felt  applied  as  preliminaries  to  plaster  east 468 

154.  Applying   plaster   cast   with  reinforcement  of   iron   strips 468 

155.  Using  counterpressure  on  the  healthy  thigh 470 

156.  Removing  iron  supports  from   the  plaster  box I7<> 

157.  A  fenestrum   for  dressing  the  wound 471 

158.  A   plaster  cast  split  for  temporary  removal 473 


ILLUSTRATIONS  XXI 

FIG.  PAGE 

159.  The  ordinary  immediate  abdominal  binder  pinned  on  in  the  operating 

room 476 

160.  An  ordinary  straight  corset.  Front  view 479 

161.  Ordinary  straight  corset.     Back  view 479 

162.  The  athletic  web  corset.     Side  view 480 

163.  The  athletic  web  corset.     Front  view 481 

164.  The  athletic  web  corset  laced.     Front  view 481 

165.  Effleurage 488 

166.  Diamond  effleurage 488 

167.  Draining  the  jugular  veins 489 

168.  Alternate  wringing  of  the  flexor  muscles 489 

169.  Kneading  of  the  patella 490 

170.  Alternate  kneading  of  the  flexors  of  the  thigh 490 

171.  Pulling  and  pushing  of  the  flexors  and  extensors  of  the  arm     ....  491 

172.  Thumbs  kneading  the   anterior  muscles   of   the  leg 491 

173.  Anterior  frictional  kneading  of  the  thigh  alternate  up  and  down     .     .  492 

174.  Fist  kneading  of  the  small  intestines 492 

175.  Circular  muscular  kneading  of  the  thigh 493 

176.  Breaking  up   adhesions 493 

177.  Cupping 494 

178.  Hacking 495 

179.  Illustrating  flat   foot   exercise   No   3.     Starting   position 510 

180.  Second  position  exercise  No.  3.     Complete  extension  avoiding  abduction 

of  foot 510 

181.  Extreme  inversion,  then  bringing  foot  back  to  starting  position     .     .     .  510 

182.  Passive  stretching  of  the  arm  and  shoulder  with  scapular  fixation     .     .  512 

183.  Thumb   kneading  and   draining   of  a   Colles'   fracture 515 

184.  Showing  apparatus  controlling  jet  douche,  needle  douche,  shower  douche, 

and  Scotch  douche,  and  manner  of  application 531 

185.  Illustrating    electric    light    cabinet    bath 533 

186.  The  direction  of  skin  incision 566 

187.  Incision  through  skin,  deep  fascia,  and  periosteum 567 

188.  Periosteum  and  bone  flap  elevated 568 

189.  B'one  flap  sutured  in  place  after  complete  division  of  all  structures  at  a 

high   level 569 

190.  The  stump  with  flaps  sutured 570 

191.  The  drop  by  drop  hypodermic  introduction  of  water,  controlled  by  sight 

feed 589 

192.  The  needle  introduced  through  a  square  of  gauze 590 

193.  Needle  and  gauze  held  in  place  by  adhesive 591 

194-^4.  A  hot-water  bottle  in  position.    B.     Novocaine  introduced  repeatedly 

during   the    operation 593 

195  and  196.    An  apparatus  for  maintaining  the  temperature  of  a  fluid  to  be 

introduced  under  the  skin 594 

197.  Instruments  and  material  used  in  direct  blood  transfusion     ....  602 

198.  Dissecting  out  the  vein 603 

199.  Placing  the  waxed  black  silk  cloth  under  the  vein 604 

200.  Placing  bull  dog  clamps  and  oiling  vein  with  a  lubricant 605 


XXI 1  ILLUSTRATIONS 

FIG.  PAGE 

201.  Vein  cut  in  two,  thread  put  through  at  one  end,  hemostat  at  other     .     .  606 

202.  Drawing    donor's    vein   through    cannula 607 

203.  Vein  drawn  back  and  tied  at  second  notch  on  cannula 607 

204.  Placing  and  tying  recipient 's  vein  over  cannula 60S 

205.  Citrate  transfusion   as  done  by  Pemberton 610 

206.  The    Kaliski    needle 611 

207.  The  Kaliski  needle  separated  into  its  component  parts 611 

208.  The  transfusion  needle  introduced  by  the  vein  transfixing  method     .     .  612 

209.  Mixing  the  blood  with  citrate  solution 613 

210.  The  recipient's  vein  held  up  and  divided 614 

211.  A  cannula  introduced  into  recipient 's  vein 614 

212.  A  form  of  cannula  which  may  be  tied  in  recipient  's  vein 615 

213.  Introducing    cannula    into    recipient 's    vein 616 

214.  Blood   entering   recipient's   vein 616 

215.  Funnel  tube  and  a  form  of  cannula  which  can  be  used  on  recipient     .     .  617 

216.  The    recipient's    wound    sutured 61S 

217.  A  convenient  compress  which  is  included  in  the  ends  of  the  suture     .     .  618 

218.  Paraffin   coating  in   process   of  application 619 

219.  Blood   running  into   tube   from   donor 620 

220.  Blood  being  driven  into  recipient 's  vein 621 

221.  The   Percy   transfusion   tube        622 


THE   AFTER-TREATMENT   OF 
SURGICAL    PATIENTS 


VOL.  I. 


CHAPTER  I 

THE  IDEAL  POSTOPERATIVE  ROOM 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

One  of  the  important  considerations  confronting  the  prospective 
operative  patient  is  the  choice  of  a  room  in  which  to  pass  his  conva- 
lescence. This  is  probably  a  matter  of  very  little  import  to  the  or- 
dinary individual  during  the  first  few  days  of  his  stay,  but  soon  the 
newness  of  his  surroundings  begins  to  wear  off,  he  is  no  longer  en- 
grossed by  his  postoperative  discomfort,  and  he  begins  an  actual  ap- 
praisement of  what  is  in  sight  and  earshot. 

The  ideal  room  should  be  situated  above  the  first  floor  of  the  hospi- 
tal or  nursing  home,  and  so  arranged  as  to  receive  the  benefit  of  a 
southern  exposure  for  sunshine  in  winter  and  breeze  in  summer. 
The  ideal  building  is  one  located  upon  high  ground  with  long  green 
lawns  sloping  to  the  street  several  hundred  feet  away,  and  the  win- 
dows placed  so  low  that  the  patient,  even  though  in  bed,  can  look  out 
upon  the  outside  world. 

The  noises  of  the  street  should  not  reach  the  patient,  neither  should 
many  of  those  arising  within  the  building.  The  same  may  be  said  of 
the  odors  from  the  serving  room  or  kitchen.  The  room  (Pig.  1)  should 
be  so  far  as  practical  removed  from  the  service  portion  of  the  house. 
If  possible,  a  private  bathroom  may  be  connected  with  the  sick  room 
(an  anteroom  alone  intervening)  on  the  one  side,  and  a  sun  parlor 
or  porch  is  to  be  desired  on  the  other.  It  is  well  to  have  one  side  of 
the  room  adjoining  a  main  hall  where  the  patient  can  be  taken  in 
bad  weather  for  frequent  rides  and  change  of  scene  as  he  improves. 
Heavy  doors  made  of  solid  wood  are  desirable,  since  these  tend  to 
eliminate  unnecessary  noise  when  they  are  closed.  All  the  openings 
should  be  spacious,  and  a  transom  over  each  door  and  window  will  be 

1 


Z  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

found  very  convenient.  To  prevent  sudden  slamming  of  doors,  a  knit 
cuff  may  be  fastened  over  the  latch   (Fig.  2). 

The  size  of  the  room  should  be  at  least  13x16  feet,  but  larger  di- 
mensions are  not  undesirable.  The  height  depends  upon  the  width  and 
breadth,  ranging  from  12  to  15  feet.  The  patient  requires  at  least 
1200  cubic  feet  of  air,  which  calls  for  80  square  feet  of  a  room,  with 
a  16-foot  ceiling;  therefore  a  room  of  the  minimum  dimensions  will 
more  than  accommodate  the  nurse  also. 

The  walls  and  ceiling  both  should  be  glazed  so  as  to  permit  of  fre- 
quent washing  and  painted  in  some  solid  color.    Probably  light  green 


HALL 

Fig.    1. — Ground  plan  of  postoperative  room,  anteroom,   and   sun   parlor. 

A,  Small  bedside  table  for  patient;  B,  foot  stool;  C,  small  stand  for  nurse;  D,  straight- 
back  chair  for  nurse;  /:'.  rocking  chair;  F,  push  button  for  signaling  nurse  (note  the  reading 
light  at  the  head  of  the  bed  next  to  signal  button);  G,  short  straight-back  chair  in  bath   room. 


is  the  best  since  this  is  cheerful  and  at  the  same  time  most  restful 
to  the  e}re. 

Polished  oak  or  pine  which  is  easily  kept  clean  makes  the  best 
floor.  The  heating  should  be  uniform  and  of  a  kind  which  is  least 
disturbing  to  the  patient.  No  doubt  the  hot  water  system  gives  as 
much  satisfaction  as  any. 

The  general  illumination  of  the  room  is  besl  secured  by  an  inverted 
reflector  hung  fairly  low  from  the  middle  of  the  ceiling,  and  con- 
trolled by  a  switch  at  the  side  of  the  door.  A  socket  should  be  located 
near  the  floor  for  a  portable  electric  reading  light  at  the  head  of  the 
bed,  and  another  socket  placed  near  the  dresser,  which  can  be  utilized 
for  a  fan,  heater,  examination  light  or  other  convenience.     The  read- 


THE   IDEAL    OPERATING   ROOM  d 

ing  light  must  be  so  placed  as  to  be  easily  manipulated  by  the  patient. 
In  addition  to  this  light,  a  signal  cord  is  constantly  kept  within  easy- 
reach  at  the  head  of  the  bed.  Every  modern  hospital  room  should 
have  telephone  connection  if  desired. 

The  furnishings  should  be  as  homelike  as  is  compatible  with  modern 
hospital  ideas.  White  enameled  iron  bedstead  (Figs.  3  and  4)  and 
mahogany  furniture  are  very  attractive.  Such  furniture  requires 
frequent  cleaning  in  order  to  look  presentable,  and  this  is  an  added 
factor  of  safety  to  the  patient.    A  small  rug  here  and  there,  which 


Fig.    2. — An   antislamming   device   used  at   the   Mayo    Clinic. 

can  be  easily  taken  out  and  cleaned  daily,  is  all  that  is  necessary 
for  a  floor  covering.  "White  scrim  sash  curtains  serve  to  detract 
from  the  bareness  which  is  sometimes  apparent  in  the  ordinary 
hospital  room.  A  bed  which  is  42  inches  wide  and  28  inches  high 
from  the  floor  to  the  top  of  the  mattress  gives  satisfaction  to  the 
patient,  though  it  is  somewhat  unhandy  for  the  nurse  at  times.  The 
kind  of  springs  which  I  have  found  to  give  the  least  trouble  from 
sagging  in  the  middle,  and  thus  causing  backache,  etc.,  and  also 
the  most  easily  cleaned  and  most  durable,  consists  of  chain  and 
cross-chain  lengths,  with  wire  side  line  from  each  end  of  the  bed 
and  with  spirals  at  the  end  of  every  separate  chain  (Fig.  6).  The 
mattress  (Fig.  4)   that  is  probably  the  best  for  postoperative  use 


4  AFTER-TREATMEXT   OF    SURGICAL    PATIENTS 

is  one  made  of  curled  hair.  Pillows  for  arm  or  leg  rests  also  made 
of  this  material,  are  desirable,  since  their  contents  can  be  washed 
or  sterilized  if  contaminated  with  blood,  etc.     The  ordinary  feather 


Fig.   3. — An   iron   bedstead   used   at  the   Mayo   Clinic.      The   curtains  are   employed   only   where 
there   are   multiple   beds   in   the   same    n 


Fig  4. — The  ideal  bed  showing  the  mattress  and  the  arrangement  of  bed  clothes  for  the 
immediate   reception   of   an   unconscious    postoperative   patient. 

.J.  Rubber  sheet  covered  with  linen  sheet:  B,  sheet  and  two  blankets  rolled  back;  C, 
linen  sheet  covering  whole  bed;  D,  mattress;   E.  linen  draw   si 


pillow  may  he  used  for  the  head  for  the  tirsi  few  days;  however,  il 
can  be  encased  in  a  rubber  slip  |  Pig.  .">  if  the  requirements  of  the 
case  so  demand. 


THE    IDEAL    OPERATING    ROOM 


A  headrest  (Fig.  6)  may  be  built  into  the  bed.  or  some  homemade 
apparatus  may  suffice.  The  bed  should  be  at  least  one  foot  away 
from  the  wall,  since  the  air  close  to  the  wall  is  frequently  stagnant. 
It  should  also  be  so  situated  that  the  foot  is  nearest  the  door,  while 


Fig.   5. — Pillows   and   rubber   slips 


Fig.   6. — A   headrest  built   in. 


the  side  is  parallel  to  the  windows,  which  best  enables  the  patient 
to  see  out.  and  at  the  same  time,  to  escape  the  glare  of  a  direct 
light,  and  any  draught  which  this  would  ordinarily  entail.  By  open- 
ing the  transoms  above  the  windows  and  doors  a  freely  circulating 


6  AFTER-TREATMENT   OP    SURGICAL   PATIENTS 

atmosphere  can  be  obtained  without  unnecessary  exposure  of  the 
patient. 

In  addition  to  the  bed,  a  leather  couch  may  be  installed  (if  the 
size  of  the  room  permits)  for  the  use  of  the  nurse  at  night,  or  to 
allow  the  patient  to  rest  during  the  day.  A  dresser  with  a  large 
mirror  is  convenient.  A  small  bedside  table  is  very  necessary  for 
the  immediate  use  of  patient  or  nurse.  A  few  vases  capable  of  hold- 
ing long-stemmed  flowers  may  be  held  in  readiness. 

In  rooms  with  the  bath  attached,  every  convenience  is  supplied 
for  the  toilet,  but  even  in  those  not  so  equipped,  a  washbasin  installed 
as  a  permanent  fixture,  or  an  ordinary  washstand,  is  highly  impor- 
tant. This  is,  however,  separated  from  the  rest  of  the  room  by  a 
three-paneled  screen  with  light  green  washable  fillings.  In  most 
hospitals  the  largest  rooms  contain  a  spacious  closet  or  wardrobe. 
This  is  a  desirable  asset,  as  many  patients  arc  particular  about  their 
clothes  and  other  belongings,  and  to  know  they  can  be  properly  cared 
for  eases  the  mind.  A  large,  comfortable  rocking  chair,  and  two 
straight  back  chairs,  with  one  footstool,  complete  the  furnishings  of 
a  most  desirable  room  for  the  housing  of  a  surgical  patient. 

The  above  represents  the  absolutely  ideal  in  its  way,  while,  as  a 
matter  of  course,  the  average  surgical  patient  who  makes  a  satis- 
factory recovery  does  so  amid  surroundings  which  are  comparatively 
inexpensive  and  unostentatious. 


CHAPTER  II 

RECORDS  AND  CHARTS 
By  Willard  Bartlett,  St.  Louis,  Mo. 

A  graphic  record,  properly  made  out,  especial  attention  being  paid 
to  the  plotting  of  the  various  curves,  enables  the  surgeon  to  orient 
himself  more  readily  on  the  occasion  of  a  visit,  than  is  possible  by  any 
other  means.  Herein  lies  the  chief  value  of  hospital  records  from  the 
standpoint  of  the  patient.  If  this  is  a  matter  of  importance  for  a 
single  day,  it  becomes  doubly  so  when  a  complication  arises  and  the 
record  of  today  must  be  compared  with  those  that  have  preceded  it. 

Accurate  records  are  of  undoubted  value  in  that  they  keep  those 
who  make  them  up  to  the  mark.  It  is  quite  reasonable  to  think  that 
the  most  useful  records  are  made  by  the  most  observing  physician  or 
nurse,  hence  they  assume  importance  when  viewed  as  a  part  of  our 
armamentarium  which  is  used  for  purposes  of  instruction.  One  has 
only  to  mention  the  possibilities  in  the  way  of  medicolegal  value  of 
accurate  and  legible  records.  In  no  other  manner  can  a  surgeon  so 
definitely  substantiate  his  impressions  and  statements  as  by  referring 
to  them.  They  have  a  further  indirect  value  in  this  connection,  as 
tending  to  show  that  painstaking  care  was  exercised  even  though 
the  result  may  not  have  been  all  that  the  patient  could  have  desired. 

Charts  and  records  will  vary  in  kind  with  the  amount  and  scope 
of  the  work  undertaken  by  the  individual.  It  is  quite  obvious  that 
the  clinic  which  confines  itself  to  private  surgical  practice  will  de- 
velop needs  different  from  those  of  a  teaching  clinic  which  is  con- 
ducted in  the  interest  of  medical  students  or  postgraduate  physicians ; 
while  the  training  of  pupil  nurses  is  also  a  factor  to  be  considered, 
and  the  appearance  of  a  chart  will  depend  to  no  slight  extent  upon 
their  native  intelligence  as  well  as  upon  their  previous  scholastic 
training. 

I  submit  herein  a  number  of  sample  charts  which  have  developed 
in  my  own  work,  without  assuming  that  they  will  perfectly  meet  the 
wants  of  every  surgeon,  but  because  I  have  found  them  exceedingly 
useful  and  hope  that  they  may  offer  suggestions  which  will  help  the 
reader  to  develop  a  system  which  may  exactly  fulfill  his  own  needs. 

It  is  logical  to  suppose  that  the  postoperative  record  of  a  case  com- 
mences in  the  operating  room  just  as  soon  as  the  wound  has  been 

7 


s 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


closed.  It  is  my  custom  to  immediately  dictate  on  the  so-called 
Anesthesia  Charts  (Fig.  7)  the  findings  and  operations  in  the  case  un- 
der discussion.  An  assistant  has  previously  filled  out  the  headings  and 


ANESTHESIA  CHART 


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110— 90-30— 

100— 80-tt — 

90—70-10 — 

80—60 

70—50 

'  -T ■-;■■■ 

FINDINGS  AND  OPERATIONS 


7. — Record    of    patient's    condition,    findings,    and    operation. 


the  anesthetist  made  observations  during  the  time  of  operation  which 
enable  her  to  quickly  plot  pulse,  respiration,  and  sometimes  blood- 
pressure  curves.     There  are  many  forms  of  chart   used  for  this  pur- 


RECORDS    AND    CHARTS 


pose  but  none  seems  to  have  found  such  extensive  favor  as  the  one 
presented. 

In  a  modern  clinic  one  is  accustomed  to  do  several  operations  in  a 


1 

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Fig.   8. — Postoperative  orders. 


day,  hence,  it  is  obviously  impossible  to  keep  in  mind,  until  ward 
rounds  are  made,  all  of  the  therapeutic  suggestions  which  present 
themselves  during  the  progress  of  the  operation.     I  have,  therefore, 


10 


AFTER-TREATMENT   OF    SURGICAL   PATIENTS 


long  been  accustomed  at  the  end  of  each  operation  to  dictate  on  the 
Hospital  Record  (Fig.  8)  in  the  lines  especially  set  aside  for  that  pur- 
pose; Orders  after  Operation.  Where  but  two  temperature,  pulse,  and 


SPECIAL  HOSPITAL  RECORD 


. 

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Fig.    9. — Chart   for   eight   observations   daily. 

respiration  observations  a  day  are  indicated,  this  form  of  chart  will 
be  found  remarkably  satisfactory.  The  amount  of  effort  devoted 
to  the  recording  of  important  items  is  reduced  to  a  minimum ;  for 


Address- 
Occupation 


RECORDS   AND    CHARTS 
ADMISSION  CHART 


11 


Medical  No 

Single        Married        Widowed 


Nationality- 


FORMER  OR  SUBSEQUENT  ADMISSIONS 
MED.  NO. 


(Obverse   Side.) 


TREATMENT  CHART 


DATE 

MEDICINES 

TREATMENT 

DIET 

REMARKS 

- 

| 

1 

(Reverse   Side.) 


Fig.    10. — Admission  and   treatment   chart. 
(Courtesy  Hospital   Standard  Publishing    Co.,   Baltimore.) 


12 


AFTER-TREATMENT    OF    SURGICAL   PATIENTS 
CLINICAL    ANALYSIS 


SPUTUM 

..« 

™. 

.™.™=, 

...... 

.LOO. 

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STOMACH 

ANALYSIS 

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Small  Mononuclear 

Large  Mononuclear 

Neutrophilia 

Eosinophils 

Baaophile 

Transit  ioncl 

Myelocytes 

CLINICAL  ANALYSIS 


i  <  (bverse   Side.) 


WARD 

MEDICAL  No. 

URINE 

„.„ 

•"- 

COLO. 

.„.„.. 

.P.O. 

.... 

..... 

.=.,... 

.to.. 

.... 

«... 

«„,..., 

..c.oscop.c.c 

Fig.   11. —  Clinical  postoperative   laboratorj    record. 
(Courtesy    Hospital   Standard   Publishing    Co.,    Baltimore.) 


( Revei 


RECORDS   AND    CHARTS 


13 


instance,  the  scratch  of  a  pen  is  sufficient  for  noting  stool,  passage 
of  flatus,  quantity  vomited,  total  urine,  change  of  dressing,  removal 
of  stitches,  or  the  withdrawal  of  drains.  Under  complications,  space 
is  given  for  the  insertion  of  the  somewhat  rare  though  extremely  im- 
portant words — distention,  sleep,  pain,  delirium,  menstruation,  hem- 
orrhage, discharge,  unconsciousness,  sweating,  involuntary  urination 
and  defecation,  etc.  The  reverse  side  of  this  sheet  is  ruled  and  at 
the  top  is  printed  Operator's  Notes. 

Where  more  detailed  observation,  especially  during  inflammatory 
processes,  is  indicated,  I  maintain  what  is  termed  a  Special  Hospital 
Record  (Fig.  9)  which  permits  curves  to  be  plotted,  showing  rise  or 
fall  in  temperature,  pulse,  leucocytes,  and  blood  pressure  every 
three  hours.    I  have  not  maintained  for  several  years  the  old-fash- 


OFFICE  VISITS 

Address 


Fig.   12. — Record  of  posthospital  examinations  of  simple  nature. 

ioned  bedside  notes,  which  were  once  so  universally  used.  If  fur- 
ther information  is  deemed  of  value  I  would  suggest  a  so-called 
Treatment  Chart  (Fig.  10)  which  allows  the  recording  of  medicines, 
treatment,  and  diet,  along  with  a  column  for  remarks  which  can 
not  be  classified. 

There  are  many  cases  involving  the  gastroenteric  tract  either  di- 
rectly or  indirectly  in  which  the  surgeon  can  keep  his  bearings  only 
by  the  use  of  an  Intake  and  Output  Chart.  It  is  especially  true 
where  there  are  grave  nutritional  changes  or  in  obstruction  of  the 
bowels,  or  where  peritonitis  prohibits  the  use  of  the  intestinal  tract 
for  the  disposal  of  fluids  which  must  then  reach  the  circulation  in 
some  other  manner. 


14  AFTER-TREATMENT   OF    SURGICAL    PATIENTS 

It  is  desirable  in  not  a  few  instances  to  make  repeated  examina- 
tions of  the  urine  which  can,  I  think,  be  of  the  greatest  possible  value 
only  if  recorded  on  some  form  of  chart  similar  to  the  one  entitled 
Clinical  Analysis  (Urine)  (Fig.  11).  A  comparison  of  results  is  thus 
much  more  easily  possible  than  if  the  most  painstaking  investiga- 
tions are  recorded  on  separate  sheets  of  paper. 

In  private  practice  I  record  every  observation  of  the  patient  sub- 
sequent to  his  leaving  the  hospital  upon  a  rather  convenient  card 
entitled  Office  Visits  (Fig.  12).  Three  months  from  the  day  of  the 
operation,  and  again  twelve  months  from  the  same  date,  the  patient 
receives  a  letter  asking  detailed  information  about  his  condition 
and  is  urged  at  the  same  time  to  write  us  any  questions  which  may 
have  arisen  in  his  own  mind.  Every  reply  to  these  epistles,  as  well 
as  all  other  communications  in  reference  to  a  certain  individual,  is 
kept  in  a  folio  devoted  to  his  history  and  hospital  records.  Surely 
no  clinical  record  can  be  considered  complete  when  the  patient 
leaves  the  hospital,  hence  the  value  of  some  kind  of  follow-up  sys- 
tem is  now  impressing  itself  more  and  more  in  many  of  our  leading 
hospitals. 


CHAPTER  III 

PRELIMINARY  CONSIDERATIONS  AND  ANESTHESIA 

By  0.  F.  MeKittrick,  St.  Louis,  Mo. 

The  outcome  of  the  postoperative  course  depends  so  much  upon  the 
proper  selection,  examination,  and  handling  of  the  prospective  opera- 
tive patient  that  we  are  forced  to  discuss  several  problems  the  correct 
solution  of  which  is  essential  to  successful  work  in  this  field.  Con- 
stant and  studious  attention  to  this  phase  of  surgery  has  done  more 
to  eliminate  the  complications  which  may  arise  later  than  has  any 
other  one  thing  at  the  disposal  of  the  man  in  whose  charge  the 
patient  is  placed  after  the  operation. 

In  ''pulling  through"  the  supposedly  hopeless  cases,  by  efficient 
and  painstaking  after-care,  one  is  impressed  by  the  prompt  reaction 
exhibited  in  some  cases,  while  in  others,  all  efforts  are  seemingly  of 
no  avail.  In  every  instance  where  interest  in  the  welfare  of  the 
patient  has  incited  sufficient  attention  to  preliminary  considerations, 
uncalled  for  and  unnecessary  complications  are  avoided,  which,  un- 
fortunately, are  often  seen  in  the  patients  not  receiving  these  con- 
siderations. 

The  selection  of  the  patient  to  be  operated  necessarily  rests,  in  pri- 
vate practice  with  the  individual  surgeon,  and  the  error  of  having 
interfered  surgically  in  an  inoperable  case,  should  always  be  con- 
sidered before  the  postoperative  treatment  is  criticized.  An  examina- 
tion, independent  of  the  surgical  condition,  must  be  made  of  the 
lungs,  heart,  and  kidneys.  For  the  busy  surgeon,  this  usually  con- 
sists in  an  ordinary  physical  examination  as  outlined  by  Cabot,1  for 
instance.  Other  examinations,  such  as  blood  pressure,  hemoglobin, 
and  clotting  time  of  the  blood,  are  also  desirable,  and  in  many  cases, 
imperative.  The  thoroughness  and  extent  of  the  examination  depends 
upon  the  condition  of  the  individual  patient.  So  also  is  the  method  of 
procedure  influenced  by  the  nature  of  the  findings.  Any  abnormal- 
ities are  rectified  so  far  as  possible,  and  the  extent  of  the  operative 
procedure  determined.  Old,  debilitated  patients  are  fed  and  given 
large  amounts  of  water  under  the  skin,  if  necessary.  The  excitable 
goiter  patient  is  calmed  as  much  as  can  be  done  by  diligent  care, 
rest,  and  medication,  and  the  highly  acid  urine  reduced  by  large 
quantities  of  alkalies,  in  addition  to  forced  water.    No  patient,  except 

15 


16  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

in  dire  necessity,  is  operated  in  the  presence  of  an  acidosis.  It  fol- 
lows then,  that  a  high  blood  pressure  is  reduced  by  proper  rest  and 
elimination,  so  long  as  no  untoward  results  are  obtained  by  so  doing, 
and  the  diastolic  pressure  remains  relatively  normal.  It  may  be 
added  that  a  hemoglobin  below  30  per  cent  was  considered  by  Miku- 
licz2 as  being  unsafe  for  a  general  anesthetic,  while  Keen,'  Da  Costa 
and  Kalteyer4  would  consider  50  per  cent  as  the  lowest  limit.  It 
has  been  shown  repeatedly  that  ether  narcosis  produces  a  decrease 
in  the  hemoglobin,"'  and  this  fact  alone  is  sufficient  to  force  pains- 
taking consideration  of  the  anemic  patient.  It  has  also  been  de- 
termined that  the  resistance  of  the  body  to  bacterial  invasion  is 
lowered  in  that  ether  decreases  the  phagocytic  power  of  the  blood. 
Therefore,  operations  on  patients  with  lowered  vitality  are  deferred 
as  long  as  the  surgical  condition  will  permit,  and  medical  treatment 
is  given  to  increase  the  general  strength. 

The  successful  preliminary  handling  of  the  individual  about  to 
undergo  an  operation  is  not  always  an  easy  task.  The  general  prepara- 
tion for  individual  eases  can  not  be  gone  into  here,  but  in  the  main, 
it  may  he  said  that  those  patients  whose  physical  findings  do  not 
warrant  special  measures  are  sent  to  the  hospital  the  morning  of  the 
day  before  the  operation.  On  admittance  they  are  given  a  warm 
tub  hath,  and  provided  with  a  gown  which  opens  down  the  front  and 
is  made  of  heavy  or  Light  material,  depending  on  the  kind  usually 
worn  by  the  patient,  as  well  as  upon  the  season.  Cathartics  are  no 
longer  employed  indiscriminately,  but  the  bowels  are  moved  before 
bedtime  hy  enema  as  a  rule.  A  pitcher  of  water  is  placed  beside  the 
lied,  and  about  one  glassful  is  ordered  for  every  waking  hour,  and  in 
addition,  an  extra  one  to  he  taken  an  hour  before  the  operation.  The 
tield  of  operation  is  prepared  and  those  who  are  strong  enough  and 
desire  to  do  so  are  allowed  1o  sit  up  out  of  bed,  so  as  not  to  decrease 
the  chances  for  a  good  night.  If  accessary,  veronal.  5  to  15  grains, 
is  given  in  a  glass  of  hot  milk  at  the  evening  meal.  The  evening 
meal  is  light  and  consists  chiefly  of  carbohydrates.  It  may  he  advisa- 
ble to  employ  aspirin,  10  grains,  and  codeine,  1  grain,  one  hour  be- 
fore bedtime  if  there  is  any  pain  oi  general  restlessness. 

In  the  morning  the  patient  is  rarely  allowed  out  of  bed,  gets  a 
light  breakfast  of  rice  or  barley  gruel  (if  the  operation  is  not  to  be 
too  early),  and  in  rectal  cases,  an  enema  of  soap  snds  is  given.  The 
patients  that  do  not  receive  the  usual  hypodermic  of  morphine  and 
atropine  are  allowed  to  walk  to  the  operating  room.  At  the  .Mayo 
Clinic,  where  the  preanesthetic  is  not  often  given,  the  patients,  while 
waiting  their  turn   to  be  operated,   are  ordinarily   permitted    to  mix 


PRELIMINARY    CONSIDERATIONS    AND    ANESTHESIA  17 

freely  in  a  room  set  aside  for  this  purpose,  and  the  importance  of 
the  coming  ordeal  is  minimized  by  conversation  with  others.  \Vhen 
the  operation  takes  place  before  the  middle  of  the  morning  and  pre- 
anesthetic drugs  are  used,  the  patient  is  kept  in  bed,  no  breakfast 
being  given,  and  is  wheeled  to  the  operating  table.  In  either  event, 
water  is  given  freely  to  ivithin  one  hour  of  the  operation. 

In  giving  preliminary  medication  we  have  followed  out  the  ad- 
monitions of  Gwathmey6  that  it  should  not  be  used — except  in  rare 
instances — in  the  "extremes  of  life  (under  seven  or  over  seventy)  ; 
acute  or  subacute  nephritis ;  a  state  of  coma ;  in  cases  where  morphine 
is  taken  with  distress  or  with  disagreeable  after-effects  and  especially 
in  cases  of  idiosyncrasy;  also  in  very  weak  and  feeble  patients  and 
in  those  with  respiratory  affection."  In  such  cases  atropine  alone 
may  be  given,  %50  to  %0o  grain,  thirty  minutes  to  one  hour  before 
the  operation,  as  a  rule  we  employ  no  medication  at  all  when  we  give 
no  morphine. 

The  administration  of  morphine  Ys  to  Y±  grain,  combined  with 
atropine,  %50  to  Yioo  grain,  is  not  employed  as  a  routine  even 
in  cases  that  do  not  fall  within  the  scope  outlined  above.  Such  is 
given  hypodermically  in  selected  eases  in  whom  its  effects  are  par- 
ticularly desired.  The  good  results  obtained  in  such  cases  are  due 
to  the  increase  of  confidence  aroused  in  highly  nervous  or  excitable 
patients,  the  lessened  amount  of  ether  required,  and  the  decrease  of 
mucous  accumulation  in  the  throat.  The  dose  enables  the  patient  to 
go  to  sleep  quickly  and  easily,  and  in  many  instances  allows  him  a 
more  pleasant  recovery  from  the  anesthetic.  Often  in  alcoholics  or 
patients  not  going  under  ether  normally,  an  additional  hypodermic 
of  morphine  Ye  grain  is  given  after  the  anesthesia  or  the  operation 
has  been  started. 

The  objections  to  such  medication  in  many  cases  should  be  sus- 
tained. Herb7  states  that  "morphine  allays  the  reflex  excitability 
of  the  air  passages,  thus  retarding  coughing  and  favoring  the  re- 
tention of  aspirated  blood  or  vomitus  in  the  trachea  or  bronchi, 
which  predisposes  to  pneumonia.  Many  people  are  unable  to  take 
morphine  without  distress  or  vomiting  and  in  such  individuals  the 
disagreeable  after-effects  of  ether  would  be  aggravated."  She  also 
notes  that  in  cases  of  accident  not  only  is  the  volatile  and  quickly  re- 
movable poison  ether  to  be  eliminated,  but  also  the  nonvolatile  mor- 
phine. She  reminds  those  men  who  give  atropine  for  the  excessive 
mucus  that  the  same  can  be  easily  taken  care  of  if  the  head  of  the 
unconscious  patient  is  turned  to  one  side  and  it  is  allowed  to  run 
out  at  the  angle  of  the  mouth. 


18  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

The  promiscuous  giving  of  such  medication,  no  doubt,  is  to  be  de- 
plored, yet  the  absolute  denial  in  every  case  can  not  be  countenanced. 
Sanders,8  resident  surgeon  at  St.  Mary's  Hospital,  Rochester,  Minn., 
stated  that  so  far  as  he  could  see  there  was  absolutely  no  difference 
in  the  results  obtained  by  those  operators  there  who  never  used 
preliminary  medication  and  by  those  who  used  it  routinely. 

The  operation  should  be  performed  as  early  after  7  a.m.  as  is 
compatible  with  convenience.  Such  a  procedure  reduces  to  a  mini- 
mum the  results  of  the  mental  agitation  which  every  patient  under- 
goes to  some  extent.  The  factor,  fear,  plays  a  more  important  role 
than  is  commonly  surmised.  Gwathmey6  states  that  over  70  per  cent 
of  cases  require  mental  as  well  as  medical  treatment  to  insure  the 
most  satisfactory  results.  He  further  quotes  Keen,9  who  says  that 
"patients  whose  thoughts  are  made  to  run  in  pleasant  channels  as 
the  anesthetic  is  first  given  usually  take  the  drug  more  quickly  than 
do  those  who  inhale  it  in  a  condition  of  mental  distress.  This  is  par- 
ticularly true  of  nervous  women  and  children.  When  the  fears  of  a 
patient  who  is  conscious  are  developed  into  the  terrors  of  semicon- 
sciousness, in  which  the  patient  imagines  the  most  frightful  accidenfs 
are  taking  place,  it  can  be  readily  understood  that  profound  nervous 
shock  is  produced."  Such  a  state  of  mind  does  not  arise  alone  from 
the  most  serious  operations  but  even  those  of  a  trivial  nature  may 
have  the  same  effects.  Often  there  is  no  outward  sign  of  this  mental 
state,  and  the  patients  may  stoutly  deny  its  presence  until  an  ex- 
amination of  the  pulse  alone  reveals  the  condition.  Children  and 
nervous  women  are  not  the  only  sufferers  from  the  fear  of  the  anes- 
thetic. Strong  and  robust  men  are  frequently  to  be  added  to  the 
list.  In  this  connection  it  may  be  added  that  among  the  cases  re- 
ported in  which  death  occurred  as  a  result  of  such  psychic  stimula- 
tion, the  majority  were  men. 

In  this  connection  it  may  be  instructive  to  recall  Bloodgood's10  case 
in  whom  fear  of  the  anesthetic  alone  caused  a  fall  in  blood  pressure 
from  140  to  80  mm.  mercury  in  ten  minutes.  One  of  the  most  strik- 
ing examples,  however,  is  a  ease  reported  by  Probyn-Williams." 
"A  nervous  boy  nine  years  old,  was  plaeed  on  the  operating  table 
preparatory  to  removing  his  tonsils  and  adenoids.  The  mask  was 
placed  over  his  face  and  a  relative  held  his  hand.  Suddenly  and 
before  a  particle  of  the  anesthetic  was  dropped  on  the  mask,  the 
patient  began  to  breathe  rapidly,  drumming  with  his  heels  on  the 
table,  and  saying  'I'm  going.'  The  mask  was  taken  off  and  at- 
tempts  made   to    quiet    him.   but   in    a    few    moments    he   was    dead. 


PRELIMINARY    CONSIDERATIONS    AND    ANESTHESIA  19 

Nothing  was  found  to  account  for  the  phenomena  except  the  fear 
which  he  had  experienced." 

In  view  of  such  statistics  no  opportunity  should  be  lost  in  en- 
deavoring to  eliminate  any  mental  disquietude  which  a  patient  under- 
goes during  the  preparation  for  even  the  simplest  operation. 

Anesthesia  at  its  best  furnishes  the  only  unpleasant  recollection 
of  the  operation  for  many  patients.  A  well-trained  anesthetist  can  do 
considerable  towards  making  the  procedure  more  endurable  and 
should  in  every  instance  be  retained.  He  should  become  acquainted 
with  the  patient  as  soon  as  he  is  admitted  to  the  hospital  and  every 
effort  be  made  to  gain  his  confidence  and  friendship.  Such  treatment 
will  go  a  long  way  toward  eliminating  the  fears  and  misgivings  which 
arise  in  the  mind  of  the  patient  as  he  waits  in  the  hospital  for  his 
call  to  the  operating  room. 

During  late  years  women  anesthetists,  usually  trained  nurses,  have 
been  employed  in  the  largest  clinics  in  this  country  and  the  practice 
has  been  upheld  and  even  advocated  by  many  of  the  latest  writers. 
Personally  I  feel  this  a  good  practice,  especially  if  she  lives  in  the 
hospital  and  can  see  the  patient  frequently.  She  is  more  expert  than 
a  man  in  soothing  the  excited  patient  especially  a  female  or  child, 
and  the  male  patients  will  brace  up  and  become  men  in  her  presence. 
Nurses  are  sympathetic,  gentle,  quick  to  observe  small  details,  and 
the  love  for  the  work  which  is  a  step  higher  than  their  chosen  pro- 
fession urges  them  on  to  exhibit  every  feminine  trait  which  is  most 
serviceable  to  the  individual  about  to  pass  through  one  of  the  most 
important  periods  of  his  life.  During  the  operation  itself  she  devotes 
her  entire  attention  to  the  anesthetic  while  the  lure  of  the  surgical 
field  does  not  exist  for  her.  The  operation,  therefore,  is  watched  just 
enough  to  inform  her  as  to  the  amount  of  anesthetic  to  be  given. 
Certainly  if  all  women  anesthetists  were  like  Florence  Henderson  at 
the  Mayo  Clinic,  no  objection  could  be  raised  against  them.  On  the 
other  hand,  a  doctor,  because  of  his  training  alone,  has  a  certain  ad- 
vantage over  the  nurse.  Men  who  make  this  work  a  study  and  who 
have  natural  ability  along  this  line,  though  rare,  are  certainly~the 
more  desirable.  They  are  not  so  apt  to  become  confused  in  emer- 
gencies and  are  generally  recognized  as  more  stable  than  the  woman 
whose  physical  makeup  forces  her  disposition  to  be  more  or  less 
uneven.  Keen  stated  that  "personality,  intelligence,  zeal,  and  quick 
wit  may  easily  be  worth  more  than  greater  knowledge, ' '  and  suggests 
that  a  woman  physician  would  be  ideal.  No  doubt  he  is  right,  pro- 
vided such  a  physician  as  he  mentioned  could  be  procured,  take  for 
example,  Dr.  Isabel  Herb  of  Be  van's  Clinic.     However,  the  ambi- 


20 


AFTER-TREATMENT    OF    Sl'RGICAL    PATIENTS 


tions  of  women  doctors  to  become  surgeons  may  cause  them  to  use 
anesthesis  as  a  "stepping  stone"  to  surgery  as  Keen  suggested,  and 
thus  defeat  the  xcvy  purpose  for  which  they  are  intended.  The  selec- 
tion like  so  many  others  of  its  kind  in  surgery  must  necessarily  rest 
with  the  individual  surgeon. 

The  preliminary  treatment  having  been  carried  out,  the  patient  is 
brought  to  the  operating  room.  The  stomach  and  the  bladder  are 
empty.  The  mouth  having  previously  been  examined  by  a  dentist 
and  all  loose,  useless  teeth  removed,  and  the  month  cleansed  repeat- 
edly with  some  month  wash  until  the  time  set  for  the  operation,  the 
individual  puts  himself  in  the  care  of  the  anesthetist.  He  is  now 
placed  on  a  well-padded  table  and  amply  protected  from  chilling 
by  sufficient  covering  as  directed  by  tin-  experl  anesthetist.  The  posi- 
tion of  the  patient  varies,  of  course,  according  to  the  operation.  At 
all  times  it   should  he  as  natural   and   comfortable  as  possible,  allow- 


ing.  13. — Position  of  patient  on  operating  tabic  showing  restraining  strap  across  lower  limbs. 

ing  free  respiration  and  circulation.  Now  is  the  time  to  think  of 
nerve  injuries  which  may  develop  during  the  after-care  and  attempt 
to  avoid  them  by  placing  the  body  and  limbs  so  as  to  escape  undue 
strain  or  pressure.  The  usual  position  is  that  as  shown  in  the  figure 
above.  Backache  is  anticipated  by  placing  a  pillow  under  the  dorsal 
curve  of  the  spine  before  the  anesthetic  is  started.  A  strap  is 
finally  placed  over  the  limbs  as  shown  in  Fig.  L3,  and  the  anesthetic 
started. 

The  choice  of  the  anesthetic  can  not  be  discussed  here  but  there 
are  a  few  points  which  deserve  attention.  It  has  been  found  that  in 
the  vast  majority  of  eases  ether  alone  can  be  used  with  greater  safety 
and  efficiency  than  any  other  anesthetic  or  combination  of  them.  In 
some  instances  gas  and  ether  or  gas  alone  has  been  employed.  In  most 
instances,  however,  where  ether  is  not  desirable,  the  local  anesthesia 
makes  a  most  excellent  substitute.  The  details  of  the  anesthesia 
(Fig.  14)  are  best  described  in  special  works  on  this  subject,  al- 
though a  word  along  this  line  would  not  be  amiss. 

Often  a  patient  asks  to  see  the  surgeon  at  the  last  moment  and 
wants  a   friend  or  relative  near  as  lie  is  about  to  begin  the  inhalation 


PRELIMINARY    CONSIDERATIONS    AND    ANESTHESIA 


21 


of  the  ether.  In  my  opinion  these  simple  requests  should  be  indulged 
provided  asepsis  be  not  prejudiced  thereby. 

Preliminary  medication  having  been  employed  the  patient  is  in 
a  frame  of  mind  to  receive  kindly  admonitions  and  encouragement 
from  the  anesthetist  who  will  not  neglect  to  use  all  the  powers  of 
hypnotic  suggestions  he  or  she  possesses,  while  ether  is  slowly  dropped 
on  the  mask  (that  devised  by  Ferguson  is  preferred  by  me). 

It  is  the  custom  of  some  anesthetists  to  protect  the  eyes  with  a 
dumb-bell-shaped  piece  of  gutta  percha  over  which  is  placed  a  layer 
of  wet  gauze  as  advised  by  Fowler.12  Others  do  not  employ  any  cover- 
ing, stating  that  such  will  only  cause  ether  fumes  to  remain  in  the 


Fig.  14. — A  mask  which  is  widely  used  for  the  administration  of  gas  and  ether  combined. 

proximity  of  the  eyes  and  thus  cause  irritation,  when  if  they  are  left 
open,  the  air  quickly  carries  the  fumes  away.  In  each  case  the  anesthe- 
tist should  use  his  own  judgment.  It  is  needless  to  say  that  all  pre- 
cautions are  taken  to  see  that  no  foreign  bodies  are  left  in  the  mouth ; 
of  course,  false  teeth,  chewing  gum,  etc.,  are  taken  out.  No  unneces- 
sary noise  or  talking  is  allowed  in  the  room  while  the  patient  is  still 
conscious ;  the  patient  gets  the  full  benefit  of  anything  said  to  him, 
and  at  no  time  is  it  allowable  for  him  to  be  left  alone  for  even  a  mo- 
ment. A  table  containing  the  mouth  gag,  tongue  forceps,  towels,  ba- 
sin for  unexpected  vomiting,  strips  of  gauze,  and  anesthetist's  chart 


22  AFTER-TREATMENT   OF    SURGICAL    PATIENTS 

is  placed  within  reach.  As  the  patient  goes  under  no  one  is  allowed  to 
restrain  him  or  speak  to  him  other  than  the  anesthetist.  How  often 
have  we  seen  a  restraining  hand  during  an  otherwise  uneventful 
anesthesia  produce  in  the  patient  the  wildest  delirium,  and  in  every 
instance  the  induction  of  narcosis  was  delayed! 

As  soon  as  the  patient  is  ready  for  the  operation  the  head  is  turned 
to  one  side  in  order  to  facilitate  the  outflow  of  mucous  and  a  strip 
of  gauze  slipped  between  the  teeth  and  the  cheek  until  one  end  reaches 
the  last  molar  tooth,  the  other  end  hangs  outside  of  the  corner  of  the 
mouth.  The  gauze  not  only  drains  excessive  fluids  from  the  mouth, 
but  also  acts  as  a  plug  against  Stenson's  duct,  and  therefore  inhibits 
to  sonic  extent  the  flow  of  saliva. 

During  the  etherization  the  Mood  pressure  is  taken  off  and  on  if 
occasion  demands  it.  As  shown  by  Earner,13  the  blood  pressure  is 
of  greater  value  in  determining  the  condition  of  the  patient  than  the 
rate  and  quality  of  the  pulse  and  gives  warning  of  danger  five  to 
twenty  minutes  earlier. 

Constant  even  anesthesia  is  naturally  desired;  viz.,  one  which  keeps 
the  patient  at  all  times  well  under,  yet  never  in  too  great  danger  of 
respiratory  failure.  With  well-trained  teams  one  will  notice  the 
anesthetist  stop  giving  ether  when  the  rectum  is  being  dilated  or  at 
such  a  time  in  the  operation  that  the  operator  in  putting  in  the  skin 
stitches  will  frequently  awaken  a  marked  reaction,  after  which  the 
patient  can  be  half  aroused  by  the  time  he  is  back  in  bed. 

Bibliography 

iCabot:     Physical  Diagnosis. 

-.Mikulicz:     Quoted  by   Keen.     Surgery. 

sKeen:      Boston   Med.  and  Surg,  -lour.,  December,  1!»15. 

4Da  Costa  and   Kalteyer:      Boston  Med.  and  Sm*g.  Jour.,  June,  1901. 

sHamburger  and   Ewing:     .lour.  Am.  Med.  Assn.,   November  8,  190S. 

eGwathmey:     Anesthesia,  1914,  p.  373. 

7Herb:      .'lour.   Am.    Med.   Assn.,    May   (i,    1911. 

sSanders:      Personal  communications. 

sKeen:     Surgery,  L906,  v,  12. 
loBloodgood:      Progr.   Med.,  December,   L912. 
uProbyn- Williams:     Clin.  .lour..   December  22,    L918. 
i-Fowler:     The  Operating  Room  ami  the  Patient,  L913,  p.  140. 
isHarncr:     Quoted  by   Keen.     Surgery. 

The  following  was  also  consulted: 

Graham:     Jour.  Am.  Med.  Assn.,  March  26,  1910. 


CHAPTER  IV 

FROM  TABLE  TO  BED 

By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Immediately  after  the  operation  and  during  the  time  the  final  dres- 
sings are  being  placed  by  the  surgeon,  the  restraint  straps  are  taken 
off  the  patient  and  all  blood  and  perspiration  quickly  removed  from 
the  surface  of  his  body  and  his  gown  replaced  by  one  which  has  been 
in  contact  with  a  radiator  throughout  the  operation.  In  the  meantime 
the  soiled  linen  in  immediate  contact  with  the  patient  and  covering 
the  operating  table  is  pulled  from  under  him  and  replaced  by  warm 
dry,  clean  sheets.  A  small  blanket  being  hastily  thrown  over  him, 
he  is  gently  lifted  by  two  or  three  assistants  and  placed  upon  a 
stretcher  bed,  mounted  on  a  four-wheeled  cart.  In  preparing  to  lift 
the  patient  care  is  taken  to  first  gently  roll  him  towards  the  assistants, 
in  order  that  he  may  be  supported  by  their  arms  rather  than  by  their 
forearms.  Otherwise  too  great  pressure  will  be  exerted  here  and  there 
by  their  hands,  which  may  cause  areas  of  soreness  or  other  discomfort 
to  develop  later. 

Any  unnecessary  pulling  or  jerking  of  the  patient  must  be  avoided 
as  such  treatment  predisposes  to  vomiting  in  the  semiconscious  indi- 
vidual. Also  the  horizontal  position  is  to  be  maintained  if  possible. 
Sudden  elevation  of  the  head  will  then  be  avoided  and  the  danger 
of  syncope  very  much  lessened.  It  may  be  well  to  add  here  that  if, 
for  any  reason,  it  is  necessary  to  carry  the  patient  to  the  bed,  the 
head  of  the  stretcher  is  not  elevated  and  in  going  upstairs  the  foot  is 
taken  first  while  in  going  down  stairs  the  7;  ead  goes  first. 

One  of  the  best  methods  employed  to  remove  a  patient  from  the 
operating  table  is  that  which  utilizes  two  long  poles  which  support 
two  pieces  of  heavy  canvas  (Fig.  15).  These  are  placed  beforehand 
on  the  operating  table  and  protected  with  a  rubber  sheeting  which 
is  then  covered  by  the  regular  linen  sheet.  The  patient  then  lies 
indirectly  upon  the  canvas  supports  during  the  operative  procedure. 
The  piece  used  for  the  upper  portion  of  the  body  is  twenty-seven 
inches  long,  twenty-seven  inches  wide  and  contains  on  either  side  two 
separate  spaces  which  will  allow  a  large  pole,  one  and  one-half  inches 
in  diameter,  to  pass  through.  The  outside  space  is  used  for  large 
patients,   and  the  inner  space  for  smaller   individuals.      The   other 

23 


24 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


piece  is  thirty  inches  in  length,  being  twenty-seven  inches  at  the 
top  and  twenty-three  inches  at  the  bottom.  It  also  contains  the 
spaces  for  the  lifting  pole,  as  described  for  the  larger  piece.  When 
the  patient  is  ready  for  the  stretcher,  the  poles,  which  are  seven  feet 
long,  are  slipped  through  the  spaces  prepared  for  them,  one  on  each 
side  of  the  patient,  and  he  is  easily  lifted  onto  the  stretcher  by  two 
assistants  without  danger  of  the  slightest  injury.  The  poles  can  then 
be  slipped  out  or  left  in  position  and  carried  on  the  cart  to  the  bed, 
where  the  process  is  repeated. 

The  stretcher  (Fig.  16)  which  receives  the  patient  is  prepared 
beforehand  so  that  no  time  is  lost  in  getting  him  ready  for  his  ride 
to  the  bed.     In  consists  of  a  mattress  pad  which  completely  covers 


Fig.    IS. — A  convenient    way    of    transferring  the   patient    from    the   operating   room   to   the 
stretcher   or   ward   carriage. 


the  to])  of  the  cart.  This  mattress  is  two  inches  thick  and  is  made  of 
curled  hair  encased  in  rubber  sheeting.  Over  this  are  placed  two 
double  half  blankets,  one  within  the  other,  so  that  the  blanket  which 
covers  the  mattress  also  covers  the  middle  blanket.  This  second 
blanket  and  the  upper  half  of  the  first  blanket  are  folded  back  upon 
themselves  and  kept  in  readiness  at  the  toot  of  the  stretcher.  Two 
towels  present  themselves,  one  in  the  center  and  the  other  at  the 
head  of  the  stretcher,  for  the  protection  of  the  bottom  blanket  from 
the  vomiting,  perspiring,  or  bleeding  patient.  Over  the  center  towel 
is  placed  a  binder,  or  a   binder  with  a  T-strap  attached  and  opened 


FROM    TABLE    TO    BED 


25 


out  ready  for  use  in  those  cases  which  require  these  assets.  At  the 
corner,  near  the  head,  two  other  towels  are  retained  for  instant  de- 
mand.   A  pillow  is  unnecessary. 

The  patient  having  been  laid  on  the  stretcher,  the  operating  room 
blanket  which  accompanied  him  from  the  table  is  discarded  and  the 
roll  of  blankets  at  the  foot  of  the  stretcher  quickly  brought  over  him. 
The  binder  is  now  fastened  over  the  surgical  dressing  around  the  ab- 
domen and  pinned  with  safety  pins,  the  slack  on  the  sides  being 
obliterated  by  these  same  means.  The  blankets  are  tucked  around 
him,  the  cranium  and  face  covered  down  to  the  nose  with  one  towel, 
the  chin  and  neck  with  the  other,  and  the  journey  to  the  room  is 
commenced. 

A  recovery  room  is  very  desirable.  Instances  of  postoperative 
pneumonia  and  other  lung  complications  are  more  often  seen  in  pa- 


Fig.   16. — Ward  carriage  ready  to  receive  patient  from  operating  table. 

A,  Towels  folded  back  for  instant  use;  B,  towel;  C,  blankets;  D,  towel;  B,  binder  (usually 
with  T -strap) ;   F,  blanket;   G,  linen  sheet;   H,  rubber  sheet  covering  mattress;  I,  blankets. 

tients  who  are  wheeled  through  a  long  corridor,  while  those  not  thus 
exposed  more  often  escape.  However,  I  consider  that  most  hospitals 
do  not  have  this  luxury,  and  therefore  think  of  the  patient  as  de- 
prived of  its  benefits. 

On  arriving  at  the  room,  the  foot  of  the  cart  is  pushed  next  to  the 
foot  of  the  bed,  if  the  poles  have  been  retained  (Fig.  17 A)  and  are  to 
be  employed  in  lifting  the  patient  from  the  cart.  The  procedure 
is  not  very  practical  unless  the  head  of  the  bed  is  low  and  the 
stretcher  carriers  can  stand  at  the  head  and  foot  of  the  bed,  re- 
spectively, while  placing  the  patient  in  bed.  If  this  method  is  not 
considered  and  the  patient  is  to  be  lifted  from  the  cart  and  then 
placed  into  bed,  the  head  of  the  cart  must  first  be  placed  next  to  the 
foot  of  the  bed  (Fig.  17B).  The  orderlies,  standing  between  the 
bed  and  the  stretcher,  then  lift  him  as  before,  simply  turn- 
ing around  with  the  patient  during  the  procedure  of  putting  him  to 


26 


AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 


bed.  It  should  be  impressed  upon  those  handling  such  individuals  to 
bear  in  mind  that  inconsiderate  holds  and  rough  handling  may  cost 
the  patient  many  days  of  suffering  from  bruised  muscles  or  strained 


Fig.   17A. — Patient  just  returned  from  the  operation.      Apparatus   shown   in   Fig.    15   was   used 
as  described  on  the  preceding  page.     Poles  are  withdrawn  in  the  direction  of  the  arrows. 


Fig.    17B. — Position  of  patient  prior  to  being  lifted   into   bed   as   described   in   the   text.      Head 
and   feet    will   travel    in   the   direction   of   the   arrows   during  the   maneuver. 


ligaments.  This  is  at  no  time  a  procedure  requiring  so  much  haste 
that  proper  attention  can  not  be  exercised  in  giving  firm  and  careful 
support  to  the  unconscious  human  load  as  it  is  placed  (not  dropped) 
upon  the  bed. 


CHAPTER  V 

IMMEDIATE  EFFECTS  OF  ANESTHESIA  AND  OPERATION 

By  0.  F.  McKittrick,  St.  Louis,  Mo. 

The  immediate  dangers  and  attendant  results  of  anesthesia  or 
operation  or  both,  can  not  be  lightly  passed  over  without  some  word 
of  comment,  since  later  complications  which  arise  in  the  after-care 
can  often  be  attributed  to  unusual  happenings  during  the  time  the 
patient  was  in  the  operating  room  or  immediately  thereafter. 

In  such  instances  the  two  great  systems  which  chiefly  concern  us 
most  are  the  respiratory  and  the  circulatory.  Respiratory  difficulties 
may  be  due,  according  to  Probyn-Williams,1  "to  local  or  central 
causes.  Of  the  former,  obstruction  to  breathing  may  arise  as  a  re- 
sult of  the  lips  and  cheeks  falling  together  during  inspiration  espe- 
cially noted  in  the  aged  without  teeth.  The  tongue,  large  tonsils 
or  adenoids  may  also  cause  serious  impairment  to  the  ingress  of  air. 
Anatomic  abnormalities,  inflammatory  swellings  in  the  mouth,  nose, 
larynx,  trachea,  or  bronchi,  must  always  be  considered  when  trouble 
presents  itself  and  preparations  undertaken  to  overcome  them  by  the 
use  of  the  nasal  tubes,  intrapharyngeal  tubes  or  in  particularly  se- 
rious cases,  intratracheal  anesthesia."  "The  first  half  hour  is  the 
period  of  greatest  danger,"  says  Keen,  and  during  this  time  the 
anesthetist  will  have  decided  on  the  method  best  to  be  used  and  have 
it  employed  by  the  time  the  surgeon  is  called. 

Difficult  respiration  often  occurs  from  inspired  vomitus  or  blood. 
I  have  seen  it  repeatedly  in  patients  who,  because  of  the  urgency  of 
their  operation,  could  not  be  properly  prepared  for  the  operation, 
and  even  in  a  few  patients  who  were  prepared.  On  one  occasion  com- 
plete closure  of  the  larynx  occurred  from  inspiration  of  an  adenoid 
which  had  just  been  cut  off  and  the  life  of  the  patient  was  saved  by 
quick  dislodgment  of  it.  Another  patient,  not  so  fortunate  as  was 
told  me,  was  choked  to  death  by  a  gauze  pack  which  had  slipped 
out  of  a  cavity  communicating  with  the  mouth  and  following  ether- 
ization suddenly  plugged  the  larynx. 

Mucus  becomes  troublesome  at  times.  It  alone  has  caused  serious 
obstruction  to  free  ingress  and  egress  of  air,  and,  in  fact,  it  is  a  com- 
mon factor  which  presents  itself  during  this  period.  Frequently  I 
have   seen   an   excessive   amount   occurring   even   in   patients   given 

27 


28  IMMEDIATE    EFFECTS    OF    ANESTHESIA    AND    OPERATION 

the  preliminary  atropine,  which  tends  to  decrease  its  production. 
Keen  tells  of  three  of  his  patients  who  almost  drowned  by  the  sud- 
den "inundation  of  mucus."  His  first  was  a  boy  three  or  four  years 
old  who,  after  the  operation  began,  started  "loud  bubbling  respira- 
tion" and  became  cyanotic  without  definite  cause.  He  was  at  once 
turned  upside  down  by  holding  bis  heels  and  "frothy  watery  mu- 
cus poured  in  a  stream  from  his  nose  and  mouth."  The  operation 
was  then  continued  successfully.  His  two  other  cases  were  adults 
whose  lives  were  saved  by  resorting  to  similar  measures.  In  the 
former  instance  a  man  was  placed  head  downwards  by  the  anes- 
thetist mounting  the  operating  table  and  holding  him  up  by  the  legs 
while  in  the  latter  case  the  Trendelenburg  position  was  utilized  by 
elevating  the  foot  of  the  operating  table.  Keen's  treatment  of  these 
cases  is  certainly  worthy  of  remembrance,  and  may  be  applied  in  the 
early  postoperative  period. 

Fowler  states  that  such  accidents  result  from  too  rapid  adminis- 
tration of  ether.  Certainly  any  acute  inflammatory  condition  of  the 
nasal  passages  will  tend  to  increa  e  the  flow  of  mucus,  hence  if  for 
no  other  reason,  a  general  anesthetic  should  not  be  given  in  such 
cases. 

Another  local  cause  for  obstructed  respiration  is  spasm  of  laryn- 
geal muscles  which  causes  a  closure  of  the  superior  aperture  of  the 
larynx.  Buxton2  states  this  is  especially  apt  to  occur  in  inflam- 
matory states  of  the  mucous  membrane.  The  canst1  of  the  condition 
may  he  due  to  the  irritating  ether  or  some  foreign  body  or  bodies 
coming  in  contact  with  the  sensitive  mucous  membrane  or  due  to 
reflex  action  incited  by  operation  procedures  on  other  parts  of  the 
body.1 

It  should  he  noted  also  that  difficult  respiration  occurs  not  infre- 
quently from  faulty  position  of  the  patient  on  the  operating  table, 
from  assistants  leaning  on  the  patient,  too  tight  bandaging  of  the 
chest  or  pleural  exudates  and  that  an  increase  in  intraabdominal 
contents  such  as  large  tumors,  ascites,  etc..  at  times  are  very  serious 
impediments  to  the  free  use  of  the  chest  ami  consequenl  perfect 
aeration  of  the  lungs. 

The  central  cause  of  respiratory  failure  is  due  to  direct  affection 
of  the  respiratory  center  in  the  medulla,  whether  it  be  a  part  of  a 
general  break-down  of  the  circulation  from  shock  or  from  loss  of 
blood  does  not  materially  matter,  since  the  treatment  in  either  event 
will  he  much  the  same. 

The  general  treatment  of  respiratory  disorders  consists  first  in  se- 
curing a  free  air  passage  for  the  patient.     This  is  best  accomplished 


IMMEDIATE    EFFECTS    OF    ANESTHESIA    AND    OPERATION  29 

by  one  who  is  acquainted  with  any  abnormalities  the  patient  may 
have  before  the  anesthetic  was  started.  If  none  exists,  the  condition 
may  have  arisen  from  some  foreign  body  which  can  be  quickly  re- 
moved. Simply  holding  up  the  jaw  may  be  all  that  is  necessary, 
and  occasionally  the  tongue  may  have  to  be  pulled  forward  with  a 
piece  of  gauze  wrapped  around  the  finger.  If  the  breathing  has 
stopped  and  the  patient  is  becoming  cyanotic,  the  mouth  is  forced 
open  with  the  gag.  the  epiglottis  is  lifted  by  the  finger,  and  rhyth- 
mical traction  on  the  tongue  is  started.  There  may  be  some  difficulty 
in  securing  the  tongue.  In  such  instances  rhythmical  tractions  on 
the  neck  will  have  the  same  effect.  The  head  is  grasped  from  be- 
hind and  the  neck  is  stretched  backward  and  forward  twenty  to 
thirty  times  per  minute.3  If  the  patient  does  not  quickly  respond 
to  this  treatment  Sylvester's  method  is  at  once  resorted  to.  This  con- 
sists principally  in  increasing  the  dimensions  of  the  chest  by  rais- 
ing and  lowering  the  arms.  The  head  is  lowered  and  the  arms  are 
first  pulled  forwards,  which  causes  forced  inspiration.  The  arms 
are  now  brought  clown  to  the  sides,  being  flexed  as  they  descend,  the 
elbows  finally  to  be  utilized  in  compressing  the  chest.  The  maneuver 
is  repeated  18  to  20  times  a  minute.  If  there  are  sufficient  as- 
sistants, the  rhythmic  traction  on  the  tongue  may  be  employed  as 
well  as  pressure  on  the  abdomen  at  the  time  the  elbows  are  being  com- 
pressed against  the  chest  walls. 

If  the  respiratory  failure  is  due  to  obstruction  by  some  foreign 
substance,  the  patient  is  at  once  inverted  as  suggested  by  Keen.7  and 
in  addition,  direct  effort  put  forth  to  free  the  passages  from  the  ob- 
struction. If  the  patient  is  an  adult  and  the  Trendelenburg  position 
can  not  be  obtained  immediately  SehaeferV  method  may  be  em- 
ployed. This  consists  principally  in  placing  the  patient  on  his  belly 
and  rhythmically  compressing  the  lowest  ribs.  If  enough  force  is  ex- 
erted the  patient's  abdomen  may  also  be  forced  against  the  table 
which  will  help  to  expel  the  air  from  the  lungs.  The  process  is  re- 
peated about  sixteen  times  a  minute. 

In  the  presence  of  such  an  accident,  unnecessary  haste  is  to  be 
condemned.  Deliberate  and  accurate  movements  over  a  long  period 
of  time  will  accomplish  more  than  hasty  and  incomplete  attempts  to 
contract  and  expand  the  chest.  One  should  not  give  up  too  soon,  for 
normal  respiration  has  been  established  after  complete  cessation  of 
respiration  for  more  than  one  hour.1 

If  there  is  any  reason  to  fear  that  the  air  is  not  getting  into  the 
lungs  from  the  efforts  exerted,  a  tracheotomy  should  be  unhesitat- 
ingly carried  out.     The  head  being  drawn  backwards,  so  as  to  put 


30  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

the  throat  on  stretch,  the  trachea  is  secured  with  the  left  thumb  and 
finger  and  an  incision  starting  just  below  the  cricoid  cartilage  is 
made  one  and  one-half  inches  long  and  extending  to  the  depth  of  the 
trachea  itself  at  the  first  stroke  of  the  knife.  About  three  tracheal 
rings  are  now  severed,  this  last  incision  starting  from  the  bottom  of 
the  wound  and  extending  upwards  towards  the  chin.  A  tracheal 
cannula  is  then  inserted  and  tied  in  place  by  passing  the  attached 
tapes  around  the  neck. 

Circuhitor}j  failure  during  or  after  anesthesia  may  occur  suddenly, 
when  it  is  called  syncope,  or  it  occurs  as  a  gradual  drain  on  the  re- 
sisting powers  of  the  organism  and  appears  as  shock  or  hemorrhage. 
The  former  coin  lit  ion  was  formerly  more  often  seen  when  chloro- 
form was  extensively  used.  It  appeared  in  apparently  well  and 
robust  as  well  as  in  weak  and  sickly  patients.  Syncope,  or  sudden 
paralysis  of  the  heart  due  to  reflex  inhibition5  of  this  organ,  is  pro- 
duced most  often  during  the  early  stages  of  the  anesthesia,  and  the 
deaths  occurring  before  any  anesthetic  was  given  were  probably 
due  to  this  affection  alone.  It  is  seen  after  the  handling  of  the  ab- 
dominal viscm  or  manipulation  of  the  main  vessels  of  the  neck. 
The  condition  has  occurred  immediately  after  the  patient  is  sud- 
denly raised  from  the  prone  position.  In  most  instances  myocar- 
dial rather  than  valvular  lesions  are  found  at  autopsy.  Henderson6 
states  that  in  a  large  percentage  of  cases  occurring  during  ether 
anesthesia  the  condition  is  due  to  unskilful  administration,  and  es- 
pecially "it  is  the  sequel  of  light  anesthesia."  He  thinks  the  effects 
are  produced  by  a  state  of  "acapnia  resulting  from  excessive  pul- 
monary ventilation  during  the  stage  of  excitement." 

The  treatment  consists  in  first  stopping  the  ether,  lowering  the 
head,  raising  the  feet,  and  administering  artificial  respiration. 

If  the  abdomen  is  already  open  direct  massage  of  the  heart  is 
carried  out.  The  limbs  are  bandaged  witli  cotton  batting  and  the 
head  is  kept  lowered  until  the  patient  reacts  to  the  treatment.  It 
may  be  necessary  to  give  intravenous  physiologic  saline  with  a  few 
drops  of  1:1000  epinephrin  as  advised  by  Sajous.7 

Venesection  is   carried   out  for  engorgement   of  the   right   heart. 

Vomiting  is  anticipated  in  very  nervous  individuals  or  in  those 
patients  who  have  not  received  proper  preoperative  care  or  lavage 
on  the  table.  Lavage  is  indispensable  if  blood  has  run  into  the  stom- 
ach from  a  wound  in  that  viscus  or  anywhere  higher  up  in  the  di- 
gestive tract.  It  becomes  of  life-saving  importance  after  any  opera- 
tive procedure  for  the  relief  of  intestinal  obstruction.  It  occasion- 
ally happens  after  ether  anesthesia   that    the  patient   vomits  before 


IMMEDIATE   EFFECTS    OF    ANESTHESIA   AND    OPERATION  31 

he  is  fully  conscious  and  is  off  the  table.  In  such  cases  the  head  is 
lowered  to  prevent  by  simple  down-hill  flow  possible  suction  of  the 
vomitus  into  the  trachea.  If  this  is  not  practical,  the  head  is  twisted 
well  to  one  side  and  the  body  lifted  over  so  that  the  vomitus  will  run 
out  of  the  mouth  if  the  expulsive  effort  of  the  patient  is  not  sufficient 
to  force  it  out.  Vomiting  at  this  stage  is  particularly  dangerous  be- 
cause of  the  possibility  of  respiratory  obstruction  and  inspiration 
pneumonia.  After  reflexes  have  been  reestablished,  these  dangers  no 
longer  exist. 

The  early  vomited  material  is  thin,  watery,  and  chiefly  saliva 
which  has  been  swallowed  during  the  early  stages  of  the  anesthesia. 
Later  on  some  of  the  mucus,  which  is  generated  by  the  ether,  finds 
its  way  into  the  stomach.  Bile  is  added  from  the  intestines  in  some 
cases  while  the  operative  procedure  goes  on,  while  in  others  blood 
from  a  wound  high  in  the  digestive  tract  may  be  admixed.  In  such 
cases  the  mouth  and  throat  are  first  freed  of  all  vomited  matter  be- 
fore lavage  is  attempted,  while  in  the  other  instances  the  stomach 
tube  is  inserted  without  further  delay. 

Ordinary  tap  water  is  used,  since  cool  water  is  sufficient  to  stim- 
ulate the  partially  paralyzed  musculature  and  therefore  aids  the  or- 
gan in  expelling  any  undesirable  contents.  Care  is  taken  that  as 
much  fluid  returns  as  is  put  into  the  stomach  to  avoid  acute  dilata- 
tion. 

Those  cases  of  shock  and  hemorrhage  which  require  intravenous 
medication,  hypodermoclysis  or  supportive  enemas  while  on  the 
table,  or  immediately  thereafter,  are  considered  under  appropriate 
special  chapters. 

The  bed  into  which  the  patient  is  deposited  was  previously  made 
up  and  warmed  with  hot-water  bottles  throughout  the  period  the 
operation  was  in  progress. 

In  preparing  a  bed  which  will  give  the  quickest  and  best  service 
to  these  patients,  it  may  be  stated  that  it  is  made  up  in  the  ordinary 
way  with  the  sheet  covering  the  mattress,  and  a  sheet,  blanket,  and 
counterpane,  in  order  of  their  mention,  over  this.  In  addition,  how- 
ever, two  rubber  drawsheets  are  placed  next  to  the  mattress,  one  at 
the  head  and  the  other  at  the  center  of  the  bed.  Between  the  two 
sheets  a  single  blanket  is  placed  which  is  covered  at  its  upper  portion 
by  an  ordinary  linen  drawsheet.  The  hot-water  bottles  are  placed 
beneath  this  blanket,  and  the  sheet,  blanket,-  and  counterpane  are 
rolled  back  to  the  side  of  the  bed.  As  soon  as  the  patient  is  put  to 
bed,  the  cover  is  rolled  over  him  and  tucked  in  at  the  foot,  without 
loss  of  time  or  unnecessary  exposure.     The  hot-water  bottles  are  re- 


32  AFTER-TREATMENT    OP    SURGICAL    PATIENTS 

moved  just  before  the  patient  is  placed  into  bed,  to  be  used  again 
as  often  as  desired. 

A  newer  method,  but  one  not  so  well  liked  by  me,  is  similar  to  that 
above,  but  lias  a  linen  drawsheet  in  place  of  tbe  single  blanket,  and 
the  top  covers,  being  already  tucked  at  the  foot  of  the  bed,  are 
rolled  back  and  retained  in  position  here.  When  the  patient  comes, 
all  that  is  necessary  then  is  to  pull  the  covers  over  him.  This  hist 
method  is  advocated  in  some  of  the  latest  teachings,  as  the  draw- 
sheet  is  much  easier  slipped  from  under  a  perspiring  and  helpless 
patient  than  is  the  blanket.  Since  the  operative  case  for  the  first  Hew 
hours  often  requires  a  change  of  bed  linen  from  perspiration,  etc., 
the  drawsheet  is  probably  the  best,  though  for  those  cases  in  shock, 
or  those  operated  late  in  the  afternoon,  I  would  not  discard  the 
blanket. 

The  anesthetist  (Fig.  L8)  should  not  desert  the  patient  during  the 
transfer  from  the  operating  table  to  the  bed  <>r  immediately  there- 
after. The  mouth  is  kept  free  of  m ileus,  and  the  jaw  pulled  forward 
if  necessary  to  mantain  a  clear  passageway  to  the  larynx,  and  a 
basin  is  kept  handy  for  any  emergency.  When  signs  of  conscious- 
ness return  and  the  pulse  and  respiration  are  satisfactory,  the  pa- 
tient is  safely  consigned  to  the  care  of  the  nurse. 

The  position  of  tin  patient  in  bed  will  depend  upon  the  nature  of 
the  operation.  In  those  cases  developing  considerable  mucus  during 
the  etherization,  and  where  it  is  particularly  desired  to  drain  the 
bronchial  tree,  the  ventral  position  is  by  far  the  best  1  have  tried. 
A  pillow  is  placed  under  the  thorax,  which  allows  the  head  to  rest  on 
a  lower  plane  than  the  chest,  and  being  turned  sideways  encour- 
ages, not  only  \'vcc  drainage  of  mucus,  but  also  the  tongue  falling  to 
one  side  gives  i'vce  and  open  passage  for  the  air.  The  diaphragm  is 
not  hampered  except  in  the  very  obese  or  the  aged.  Such  do  not 
take  kindly  to  this  posture,  and  these  individuals  are  turned  on  the 
side,  a  bedrest  or  pillow  supporting  them  in  this  position.  The  su- 
pine posture,  which  is  so  commonly  seen,  is  not  desired  if  for  no 
other  reason  than  that  mucus  accumulates  in  the  throat  and  lungs 
to  such  an  extent  thai  frequently  the  patient  passes  through  many 
hard  days  getting  rid  of  it,  to  say  nothing  of  hypostases. 

In  such  patients  also  I  have  found  it  extremely  helpful  to  start 
inhalations  of  steam  even  before  the  individual  is  fully  awake  from 
the  anesthetic.  Such  will  materially  assist  in  the  early  removal  of 
the  accumulated  secretions  and  thus  prevent  in  many  cases  pul- 
monary complications. 


IMMEDIATE    EFFECTS    OF    ANESTHESIA   AND    OPERATION  66 

"Ether  is  eliminated  unchanged  chiefly  by  way  of  the  lungs  and 
very  slightly  through  the  kidneys  and  skin.6 ,7  With  this  in  view  it 
is  particularly  important  in  addition  to  keeping  the  air  passages  free 
to  also  see  that  the  air  in  the  room  is  pure  and  of  even  temperature. 
Usually  68°  is  found  very  desirable  for  all  purposes." 

The  recovery  from  the  anesthetic  is  commonly  accompanied  by 
more  or  less  delirium  and  restlessness.  In  some  cases  the  patient  is 
excitable '  and  noisy,  very  talkative  and  thrashes  about  aimlessly  and 
often  his  movements  are  most  violent.  He  should  not  be  restrained 
at  first,  but  attempts  should  be  made  to  attract  his  attention  in  an 
effort  to  persuade  him  to  be  quiet.    In  the  meantime  the  parts  of  his 


Fig.   18. — A  convenient  method  of  washing  an  eye  which  has  been  irritated  during  anesthesia. 

body  which  have  become  exposed  to  the  cold  as  a  result  of  his  move- 
ments are  covered,  and  special  precaution  taken  to  prevent  unnecessary 
chilling.  In  the  majority  of  cases  even  after  the  initial  delirium  has 
passed  and  the  patient  is  conscious  he  will  exhibit  considerable  rest- 
lessness. By  careful  observation  one  is  frequently  able  to  determine 
the  cause  and  at  once  correct  it  to  the  patient's  satisfaction.  It  may 
be  due  to  concern  as  to  the  outcome  of  the  operation  or  to  mental 
distress  previous  to  the  etherization.  The  reassurance  of  a  kind, 
attentive  nurse  will  do  more  to  alleviate  the  restlessness  of  a  patient 
who  is  not  in  pain  than  will  most  drugs.  The  changing  of  the  posi- 
tion or  the  moving  of  a  limb,  acceding  to  the  wishes  of  the  patient 
concerning  his  comfort  as  to  bed  clothes,  loosening  a  tight  bandage, 
washing  his  mouth,   placing   a  pillow  under  his  back,  readjusting 


34  AFTER-TREATMENT    OP    SURGICAL    PATIENTS 

those  under  his  shoulders  or  head,  and  many  other  measures  carried 
out  even  though  many  are  to  satisfy  childish  wishes,  arc  the  en- 
deavors which  satisfy  his  desire  for  comfort. 

If,  in  spite  of  every  effort  to  comfort  him,  the  patient  becomes 
worse,  he  is  restrained  by  assistants  just  enough  to  prevent  him 
from  becoming  chilled  from  exposure,  from  injuring  himself  or 
others,  or  doing  any  damage  to  his  surroundings.  In  some  instances 
(when  short  of  help)  it  become-;  necessary  to  put  a  restraining  sheet 
over  his  body,  but  at  no  time  should  the  minor  movements  of  bis 
limbs  be  restricted,  as  this  particularly  makes  the  patient  more  un- 
tractable.  In  these  cases  it  becomes  necessary  to  give  morphine  un- 
til quiet  is  secured.  After  the  effects  of  this  drug  wear  off,  as  a  gen- 
eral rule,  patients  wake  up  docile  and  in  their  right  senses. 

Some  of  our  modern  operators  do  not  give  a  preanesthetic  drug, 
reserving  such  medication  until  this  period  when  small  doses  are 
continued  over  short  periods  of  time  until  the  patient  is  asleep  and 
has  passed  a  comfortable  night. 

Whether  medication  is  utilized  for  the  condition  or  not  it  is  very 
important  to  keep  the  patient  undisturbed  by  noise;  the  window- 
blinds  are  to  be  pulled  down,  the  room  darkened,  and  the  patient 
not  allowed  to  talk,  but  told  to  go  to  sleep.  Visiting  in  this  early 
period  is  prohibited,  and  so  long  as  the  general  condition  is  satis- 
factory the   patient    is   not    disturbed    under  any   circumstances. 

Kestlessness  due  to  causes  other  than  the  anesthesia,  such  as  pain, 
hemorrhage,  shock,  etc.,  is  treated  under  the  respective  headings.  I 
believe  most  of  the  restlessness  which  in  earlier  times  could  not  be 
explained  by  something  in  the  patient's  condition  was  the  result  of 
acid  intoxication  and  should  have  been  treated  by  earlier  feeding. 
morphine,  alkalies,  much  water,  etc.  Eowever,  in  every  case  this 
possibility  is  considered,  and  in  the  proctoclysis  which  is  started  as 
soon  as  the  patient  comes  from  the  operating  room  in  the  work  of 
some  surgeons,  a  five  per  cent  glucose  solution  in  plain  tap  water  is 
administered.  In  addition  a  teaspoonful  of  sodium  bicarbonate  is 
placed  in  each  pint  of  proctoclysis  water  for  the  first  twenty-four 
hours. 

Sweating  is  a  common  occurrence  in  patients  just  after  operation. 
Ether  in  itself  dilates  the  superficial  capillaries  and  the  resulting 
perspiration  all  over  the  body  during  a  shorl  anesthesia  in  healthy  in- 
dividuals dues  nut  cause  alarm.  However,  extensive  sweating  through- 
out and  after  a  long  and  tedious  operation  is  noted  with  concern  even 
in  the  most  rugged  as  it  is  weakening  to  the  patient  and  often  a 
definite  sign  of  shock,   hemorrhage,  etc.     In  the  latter  instances  it 


IMMEDIATE    EFFECTS    OF    ANESTHESIA    AND    OPERATION  35 

is  more  or  less  cold  and  clammy  and  has  an  altogether  different 
meaning  from  the  usual  perspiration.  In  any  case  where  the  pa- 
tient is  allowed  to  sweat  profusely  the  danger  of  chilling  with  its 
subsequent  effects  is  increased  and  should  not  be  allowed  over 
any  length  of  time,  even  in  the  operating  room,  much  less  after 
he  returns  to  bed.  In  such  patients  measures  are  taken  to  relieve 
the  condition  first  by  avoiding  tco  much  cover  after  the  body  has 
been  wiped  dry  and  in  some  instances  atropine  hypodermically  is 
employed  with  good  results.  In  every  case  the  general  condition  of 
the  patient  must  be  considered  and  treatment  carried  out  to  elimi- 
nate, if  possible,  the  existing  difficulty,  such  as  hemorrhage,  shock, 
etc. 

Sweating  is  often  prolonged  and  intensified  by  the  injudicious 
use  of  too  many  oed  covers,  especially  in  hot  weather.  A  nurse  fre- 
quently follows  out  some  routine  when  common  sense  dictates  that 
she  be  guided  by  the  amount  of  moisture  on  the  patient's  skin.  It 
has  not  been  uncommon  in  my  experience  to  find  a  patient  who  is 
only  half  awake  vainly  endeavoring  to  free  himself  from  perspira- 
tion-soaked linen  while  his  attendant  readjusts  the  blankets  with 
misdirected  zeal. 

Bibliography 

iProbyn-Williams :     Anesthetics,  1901,  p.  36. 

2Buxton:      Anesthetics,   1900,  ed.  3,  p.  140. 

^DePage:     Jour,  de  chir.  et.  Ann.  de  la  Soe.  Beige  de  ehir.,  January,  1904. 

4Schaefer:      Jour.  Am.  Med.  Assn.,  1908,  li,  801. 

sEmbley:      Brit.  Med.  Jour.,  April,  1902. 

6 Henderson:     Surg.,  Gynec.  and  Obst.,  August,  1911. 

7Sajous:   Analytic  Cyclopedia  of  Practical  Medicines,   1916,  iv,   668. 


CHAPTER  VI 

EARLIEST  SUBJECTIVE  MANIFESTATIONS 
By  <).  P.  McKittrick,  St.   Louis,  Mo. 

Pain. — One  of  the  first  eomplaints  made  by  the  postoperative 
patient  on  returning  to  consciousness  is  pain.  This  if  due  to  the 
actual  operative  procedure  should  be  at  once  relieved.  William  J. 
Mayo  taught  us  long  ago  to  give  morphine  during  the  first  twenty- 
four  hours  for  the  pain  which  we  make;  viz.,  by  cutting,  retracting, 
suturing,  etc.  The  discomfort  caused  by  such  procedures  is  re- 
lieved best  by  this  drug  and  it  is  given  by  us  if  there  be  no  contra- 
indications for  its  use,  regardless  of  the  amount  until  full  relief  is 
experienced    or    its    physiologic    effects    obtained.     The    respiration 

should  be  watched  carefully  in  every  case  and  if  it  b< mes  less  than 

12  per  minute  the  <\\'\\<j;  is  discontinued  at  once.  Usually  one  dose  of 
gr.  '  i  hypodermically  is  sufficient.  It  should  lie  borne  in  mind,  how- 
ever, that  one  must  first  get  some  idea  as  to  the  location  and  nature 
of  the  pain  since  it  too  often  happens  that  some  local  cause  irrespec- 
tive of  the  operal  ion  is  to  be  found.  A  pin  from  an  abdominal  binder 
may  have  caught  the  skin  or  a  bandage  may  be  too  tight.  Strong 
chemicals  used  about  the  patient  during  the  operation  may  be  an  ex- 
citing  cause.  Muipliy1  state-,  thai  the  common  household  flea  lias 
caused  considerable  distress  in  these  cases. 

Abdominal  operations  give  more  pain  as  a  rule  than  operations 
elsewhere  over  the  body.  In  addition  to  the  actual  trauma  produced. 
the  excursions  of  the  diaphragm  and  the  abdominal  movements 
caused  by  coughing,  vomiting,  etc..  materially  aggravate  the  con- 
dition. Often  after  these  operations  it  is  particularly  useful  to  give 
the  morphine  before  the  patient  is  fully  conscious  and  he  will  then 
pass  from  the  sleep  due  to  the  anesthetic  into  that  produced  by 
morphine,  and  in  many  cases  escape  the  frequent  nausea  and  vomit- 
ing and  genera]  distress  of  the  immediate  effects  of  the  anesthesia. 

In  neurotic  patients  especially  I  have  carried  this  out  with  mosl 
excellent  success,  in  this  class  pf  cases  also  it  is  commonly  noted 
that  the  most  excruciating  pain  is  often  felt,  and  it  seems  to  matter 
very  little  whether  the  operation  was  an  extensive  one  or  not.  Ho- 
over, the  extent  of  the  operation  is  never  an  indication  of  the  de- 
gree of  pain  even  in  the  mosl  phlegmatic,  neither  can  the  amount  of 
anodyne  to  be  employed  be  so  determined. 

36 


EARLIEST    SUBJECTIVE    MANIFESTATIONS  37 

Finney2  states  ''that  there  is  a  definite  psychology  of  pain  diffi- 
cult to  understand,  perhaps,  but  nevertheless  well  recognized  by 
every  intelligent  observer.  Some  one  has  said  that  pain  is  the  re- 
sultant of  two  factors,  the  lesion  and  the  patient,  and  in  order  to 
arrive  at  an  intelligent  appreciation  of  its  true  significance  both 
must  be  thoroughly  understood." 

"The  mental  state  of  the  sufferer  varies  greatly  in  different  in- 
dividuals and  at  different  times.  Frequently  he  will  unintentionally 
deceive  his  physician  by  his  inability  accurately  to  describe  his  sen- 
sations, especially  is  this  true  of  pain,  which  is  purely  subjective. 
Again  he  may  do  so  intentionally  by  false  statements  as  to  its  char- 
acter, location  and  intensity.  In  some,  pain  brings  out  the  heroic, 
often  to  a  very  unexpected  degree.  In  others,  it  develops  the  hitherto 
unsuspected  'yellow  streak.'  It  does  not  always  follow  that  because 
a  patient  bears  what  appears  to  be  a  great  amount  of  pain  with  re- 
markable patience,  that  that  individual  is  more  deserving  of  credit 
or  shows  greater  self-control  than  the  one  who  does  not ;  for  it  is  a 
well-established  fact  that  pain  is  not  felt  to  the  same  degree  by  all 
individuals  alike,  some  are  much  more  tolerant  of  it  than  others." 

Pain  occurring  after  operations  upon  bones,  joints,  etc.,  and  where 
it  becomes  necessary  to  apply  plaster  casts  while  the  patient  is  under 
anesthesia  should  be  given  most  attentive  care.  These  cases  are  al- 
ways allowed  to  become  fully  conscious  and  the  cast  then  inspected  to 
see  that  no  unnecessary  pressure  is  exerted  anywhere.  The  circula- 
tion and  sensation  are  carefully  studied  and  though  the  patient  com- 
plains of  no  pain,  any  coldness,  blueness,  or  unexplained  swelling  or 
numbness  of  the  parts  are  at  once  corrected  by  cutting  "windows" 
in  the  cast  or  even  cutting  it  throughout  its  whole  length,  and  after 
relieving  the  pressure,  the  severed  portions  are  held  together  with 
adhesive. 

Pain  produced  by  splints  of  any  kind  is  not  to  be  neglected 
a  single  moment.  They  are  difficult  to  apply  to  an  unconscious 
patient  and  it  is  to  be  expected  that  complaint  will  often  be  made 
and  that  some  readjustment  will  be  necessary. 

A  case  is  brought  to  mind  in  which  a  resection  of  the  jaw  was  per- 
formed for  carcinoma.  The  teeth  on  the  sound  side  were  wired  so 
as  to  keep  the  parts  as  nearly  as  possible  at  rest.  The  patient,  on 
awakening  from  the  anesthetic  complained  of  pain  in  his  neck  and 
face  and  the  usual  morphine  was  ordered  without  particular  atten- 
tion being  given  the  inside  of  the  mouth.  The  patient  passed  a 
miserable  night  though  a  second  dose  of  morphine  was  administered. 
During  the  next  day  he  still  complained  of  the  neck  and  face.  Ex- 
amination revealed  that  the  wire  had  broken  and  that  one  sharp  end 


38  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

had  prodded  the  gums  until  a  severe  wound  had  been  inflicted.  Re- 
moval of  the  wire  splint  gave  instant  relief. 

Other  instances  may  be  mentioned  in  which  too  tightly  applied 
bandages  caused  swelling  of  the  parts;  the  limitation  of  an  improp- 
erly applied  bandage,  particularly  one  made  of  crinolin  or  plaster 
of  Paris  has  caused  such  pressure  with  pain  as  to  produce  extensive 
excoriation  of  the  skin.  How  often  do  those  patients  on  whom  the 
perineal  straps  were  applied  too  tightly  present  the  next  morning 
a  denuded  area  of  epidermis  the  entire  width  and  length  of  the  strap. 
On  the  other  hand  too  loosely  applied  bandages  will  permit  the 
dressings  to  slip  about  over  the  wound  and  cause  unnecessary  pain 
and  exposure  to  infection.  Adequate  inspection  will  usually  decide 
the  point  in  question  and  the  proper  course  to  be  taken. 

Pain  is  anticipated  in  amputation  by  placing  the  stump  with  its 
dressing  in  a  pillow  splint.  The  muscular  spasm  sometimes  experi- 
enced in  these  casrs  is  severe  and  such  simple  measures  will  prevent 
this  difficulty.  However,  if  any  pain  does  occur,  readjustment  of 
the  splint  and  massage  of  the  muscles  will  usually  give  instant  re- 
lief. 

Pain  about  the  operative  wound  during  the  first  twenty-four 
hours  does  not  compel  inspection  except  in  particular  instances 
where  it  may  become  necessary  to  shorten  hard  rubber  drains  which 
are  found  to  be  too  long  or  to  lessen  the  pressure  of  the  dressing  over 
them.  The  ends  of  silk  worm  sutures  may  be  irritating  the  wound  or 
occasionally  the  incision  has  been  too  tightly  closed. 

Pain  occurring  after  twenty-four  hours  is  usually  due  to  causes 
other  than  operation  and  they  must  be  sought  for  and  the  proper 
specific  treatment  instituted.  The  most  common  cause  is  abdominal 
distention  by  gas,  and  measures  are  promptly  instituted  for  its  re- 
lief. However,  acute  cystitis  is  another  frequent  cause  in  gyneco- 
logic operations,  while  various  acute  inflammations  in  other  parts  of 
the  body  play  no  little  part  in  the  late  pain  which  some  patients 
suffer.  Treatment  locally  for  each  individual  complaint  is  insti- 
tuted, but  morphine  is  withheld  except  in  eases  urgently  demanding 
its  use.  Commonly  the  cystitis  will  disappear  with  20  to  25  grains 
sodium  citrate  every  four  hours  together  with  boric  acid  irrigations 
once  or  twice  a  day.  and  the  inflammations  elsewhere  art1  relieved 
by  the  application  of  the  ice  bag  or  upon  putting  the  parts  at  rest 
by  means  of  adhesive,  etc. 

The  time  of  day  serins  to  influence  the  patient  to  the  end  that 
discomfort  is  more  marked  at  night.  Whether  it  is  due  1<>  the 
fact   that  at   this  period  the  patient  has  less  to  attract  his  attention 


EARLIEST    SUBJECTIVE    MANIFESTATIONS  39 

so  that  he  can  therefore  center  upon  himself,  or  because  his  senses 
are  more  acute  at  this  time,  it  is  difficult  to  say.  Certain  complicat- 
ing lesions  we  know,  are  more  painful  at  night,  particularly  those 
affecting  bone  or  clue  to  syphilis.  It  is  well  at  any  rate  to  bear  this 
fact  in  mind  and  to  see  that  such  patients  are  cared  for  at  this  time. 

Any  sudden  changes  in  the  weather,  especially  from  good  to  bad, 
will  often  elicit  aches  and  pains  which  can  not  be  otherwise  ac- 
counted for.  Pain  in  the  female  is  much  better  borne  than  that  in 
the  male.  It  has  been  said  that  response  to  painful  stimulation  of 
all  kinds  is  much  more  sluggish  in  them  than  in  the  opposite  sex. 
The  matter  deserves  particular  attention  and  it  is  naturally  to  be  ex- 
pected that  our  male  brothers  will  be  more  or  less  sensitive  on  this 
subject. 

The  second  postoperative  day  should  require  less  anodynes  than 
the  first.  Rarely  is  it  necessary  in  this  period  to  give  morphine  at 
all  except  in  very  small  doses  and  most  commonly  codeine  with  as- 
pirin will  suffice  for  any  ordinary  discomfort  the  patient  has.  As- 
pirin is  given  in  5-  to  10-grain  doses  with  y2  to  1  grain  of  codeine. 
Suppositories  of  1  to  2  grains  of  opium  are  very  efficacious  in  pain 
from  operative  procedures  about  the  pelvis.  These  are  not  needed 
long  and  soon  the  simpler  and  decidedly  less  harmful  drugs  will 
allay  any  pain  or  discomfort  that  may  arise. 

Thirst. — Thirst,  which  is  of  common  occurrence  after  a  general 
anesthetic,  can  to  a  great  extent  be  prevented  by  allowing  the  pa- 
tient to  drink  liberal  quantities  of  water  up  to  an  hour  before  the 
operation,  when  I  insist  on  one  glassful  being  taken.  This  matter 
must  have  careful  attention,  since  many  unthinking  nurses  still  send 
all  patients  to  the  operating  room  dehydrated.  It  is  particularly 
unfortunate  that  such  should  be  the  case  since  the  cause  of  the  thirst 
in  the  first  place  is  in  great  part  due  to  loss  of  the  body  fluid  through 
preoperative  purgation  or  to  increased  urination  in  some  cases  from 
sheer  nervousness ;  while  the  sweating,  increased  mucus  secretion,  or 
loss  of  blood  during  the  operation  adds  to  the  dehydration.  Finally, 
the  postoperative  vomiting  with  the  attendant  after-effects  of  ether 
together  with  those  of  morphine  and  atropine  which  inhibit  the  mu- 
cus secretion  and  thereby  increase  the  dryness  of  the  oral  mucous 
membranes,  increases  the  torture  from  prolonged  thirst.  Formerly 
all  fluids  per  mouth  were  prohibited  for  the  first  twenty-four  hours, 
it  being  considered  that  such  measures  would  stimulate  postoperative 
nausea  and  vomiting.  Happily  such  an  idea  has  been  superseded  by 
the  more  sane  opinion  that  the  demands  of  nature  should  be  granted. 
Consequently,  just  as  soon  as  the  patient  is  awake  his  complaint  of 


40  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

thirst  is  immediately  met  by  giving  sips  of  hot  water  for  the  first 
few  hours.  The  taste  of  the  ether  and  the  sticky  mucus  and  saliva 
are  cleared  out  of  the  mouth  by  allowing  the  patient  to  rinse  it  with 
equal  parts  of  rose  water  and  glycerin  or  to  this  may  be  added  a 
little  lemon  juice.  If  he  is  unable  to  do  this  himself  the  nurse  can 
swab  his  mouth  out  with  equal  parts  of  glycerin  and  4  per  cent  boric 
acid  solution.  Sometimes  a  little  weak  tea  is  better  than  the  plain  water 
in  allaying  the  immediate  effects  of  the  condition.  Very  soon  the  hot 
water  can  be  replaced  by  cool  water,  but  this  given  in  moderate 
quantities.  The  continued  use  of  water  in  very  small  amounts  is  not 
an  especially  good  practice,  as  nausea  and  vomiting  are  invited  and 
the  irritating  mucus  in  the  stomach  secreted  during  the  operation  is 
not  washed  out.  Fairly  liberal  quantities  of  water,  on  the  other 
hand,  do  not  require  so  often  disturbing  the  patient,  more  fluid  is 
absorbed  and  if  the  patient  vomits  the  quicker  will  the  gastric  mu- 
cous membrane  be  cleansed  and  the  normal  tone  of  the  musculature 
again  restored.  I <■<■  water  is  severely  condemned  as  a  drink,  neither 
should  it  he  used  to  wash  onl  the  month.  In  order  to  facilitate  the 
taking  of  fluids,  a  bent  ulass  tube  is  placed  in  the  glass  |  Pig.  19)  and 
the  liquid  sucked  into  the  mouth  without  it  being  necessary  to  raise 
the  patient. 

In  every  case  even  though  the  preoperative  preventive  measures 
to  relieve  thirst  have  been  carried  out.  this  phase  of  the  treatment 
must  he  considered  if  there  has  been  a  marked  hiss  of  fluids  during  the 
operation;  physiologic  salt  solution  or  distilled  plain  sterile  water 
should  1h>  poured  into  the  abdominal  cavity.  IF  this  i>  not  practical 
an  enema  of  plain  water  or  hypodermoclysis  should  he  administered 
on  the  table. 

As  a  routine  before  the  patient  is  awake,  slow  proctoclysis  of  tap 
water  is  given  by  many  alone  or  in  conjunction  with  glucose  suffi- 
cient to  make  a  5  per  cent  solution,  and  to  this  also  at  times  is  added 
sodium  bicarbonate  of  the  same  strength.  \i\  those  urgently  re- 
quiring larger  amounts  of  water  quickly,  hypodermoclysis  or  even 
intravenous  injections  are  employed.  Unfortunately,  however,  the 
psychology  of  thirst   definitely  indicates  the  swallowing  of  fluid. 

Nausea  and  Vomiting.-  Nausea,  and  often  retching  and  vomit- 
ing, are  particularly  common  after-effects  of  a  general  anesthetic. 
Usually  the  vomiting  from  ether  takes  place  early  during  the  period 
in  which  the  patient  is  recovering  as  noted  above,  and  frequently  it 
is  of  such  short  duration  that  he  is  unconscious  of  its  presence  and 
does  not  remember  it  afterwards.  However,  not  all  patients  are  des- 
tined  to  such   good    fortune,  and   it    is  so  common  to  see  this  conipli- 


EARLIEST    SUBJECTIVE    MANIFESTATIONS 


41 


cation  for  hours  and  even  days  continuously  or  intermittently  that 
further  discussion  and  attention  must  he  given  it. 

The  causes  for  such  a  condition  can  often  be  traced  to  the  method 
of  ether  administration,  trauma  produced  by  the  surgeon,  or  un- 
necessary handling  of  the  patient  immediately  after  the  anesthetic. 
Halperin3  states  "that  there  is  more  vomiting  from  five  minutes  of 
an  irregular  anesthesia  than  from  one  hour  of  an  even  one.  Ex- 
cessive stimulation  by  hypodermic  injections  during  anesthesia  may 
be  a  contributing  cause  also."  A  protracted  anesthesia  and  a  long 
fatiguing  operation  during  which  extensive  handling  of  the  stomach 
and  intestines  has  taken  place  certainly  adds  to  the  frequency  of  the 


Fig.    19. — A  convenient   scheme   for   the    early    administration   of   fluids. 


disturbance.  Operations  upon  highly  nervous  patients  or  upon  those 
with  improperly  prepared  gastrointestinal  tracts  are  commonly  fol- 
lowed by  protracted  vomiting.  Patients  starved  to  excess  without 
proper  food  compensation  before  operation  develop  an  early  acidosis 
(if  this  is  not  already  present)  and  rarely  fail  to  exhibit  severe 
nausea  and  vomiting  as  a  result  of  this  complication  alone. 

After  the  anesthetic  any  body  movement  tends  to  increase  vomit- 
ing, and  this  should  be  borne  in  mind  during  the  period  of  imme- 
diate recovery  when  the  sufferer  should  be  kept  absolutely  quiet 
in   a  dark  room  and  prevented  from  talking. 

Nausea  and  vomiting  may  be  caused  by  irritation  of  any  periph- 


42  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

eral  branch  of  the  vagus  nerve.  Buxton  says  that  when  it  arises 
"from  cerebral  or  cerebellar  conditions  it  may  be  due  to  the  head 
having  been  kept  at  too  low  a  level.  Unless  there  is  obvious  ische- 
mia of  the  brain,  prolonged  depression  of  the  head  especially  in 
plethoric  persons  will  tend  to  produce  postanesthetic  sickness." 

Nausea  and  vomiting  may  be  the  result  of  renal  complications 
such  as  uremia  or  the  forerunner  of  some  infectious  disease  such  as 
pneumonia,  etc.,  or  may  be  manifestations  of  chronic  alcoholism, 
nervous  dyspepsia  or  an  actual  lesion  in  the  gastrointestinal  tract. 
Beginning  peritonitis  or  intestinal  obstruction  may  be  an  inciting 
cause.  Reflex  vomiting  from  pressure  of  drains,  packs,  headache, 
etc.,  can  not  be  too  lightly  passed  over. 

Treatment  first  consists,  provided  there  be  no  specific  contraindi- 
cation, in  allowing  a  liberal  quantity  of  water  per  mouth.  This,  as 
a  rule,  will  be  immediately  returned,  and  with  it  the  local  irritating 
foreign  substance,  whether  it  be  food  taken  before  the  anesthesia,  or 
mucus,  saliva,  blood,  etc.,  which  have  entered  the  stomach  during 
the  etherization,  and  not  been  returned  during  the  initial  vomiting 
on  the  table  or  during  unconsciousness. 

The  giving  of  sufficient  water  by  month  in  these  cases  can  not  be 
too  thoroughly  impressed  upon  the  timid  person  in  charge  of  such 
a  patient.  One  who  has  gone  through  it  knows  the  torture  of  con- 
tinuing to  retch  after  the  stomach  has  been  emptied.  It  is  alle- 
viated only  by  allowing  one  to  drink  a  glassful  of  warm  or  not  too 
cool  water.  This  is  repeated  as  often  as  the  patient  vomits,  care 
being  taken,  of  course,  that  the  stomach  returns  as  much  as  it  gets, 
since  otherwise  an  acute  dilatation  may  be  caused. 

I  learned  a  never-to-be-forgotten  lesson  in  the  days  when  no 
patient  was  given  water  for  the  first  twenty-four  hours.  A 
woman  who  suffered  particularly  from  nausea  and  retching  managed 
to  get  her  hands  on  a  flower  pot,  which  her  nurse  had  just  filled 
with  water,  and  drank  the  turbid  fluid  with  evident  relief  of  symp- 
toms after  vomiting  once  more.  This  suggested  a  self-evident  thera- 
peutic procedure  which  has  been  followed  ever  since  with  highly 
gratifying  results. 

Luke*  reports  an  instance  where  a  young  woman  drank  the  con- 
tents of  a  rubber  hot  water  bottle  "immediately  after  an  ovariotomy, 
without  any  apparent  discomfort  or  harm,"  and  others  have  re- 
ported similar  occurrences,  a  thing  which  has  done  more  to  advance 
the  present  humane  treatment  of  these  patients  than  any  other  one 
thing. 

In  instances  where  it  is  not  desirable  to  use  the  stomach   lube  and 


EAELIEST    SUBJECTIVE    MANIFESTATIONS  43 

in  those  whose  stomachs  have  been  reasonably  well  washed  by  the 
procedure  described  above,  medication  may  be  resorted  to.  although 
not  much  is  accomplished  in  this  way.  An  ice  bag  or  hot-water  bag 
is  placed  over  the  epigastrium.  In  very  nervous  individuals  a  good 
placebo  is  the  old-time  mustard  plaster  placed  over  the  pit  of  the 
stomach.  Sodium  bicarbonate  in  20-grain  closes  in  a  little  warm 
water  or  yi2  to  ^§  §T-  cocaine  hydrochloride5  may  prove  of  value.  A 
little  champagne  or  ginger  ale  at  times  gives  relief.  Ferguson6 
uses  liquid  petrolatum  which  protects  the  mucous  membrane  of  the 
stomach  against  any  possible  continued  excretion  of  the  ether  by  this 
viscus.  This  is  considered  by  him  better  than  olive  oil  which  has 
been  used  in  such  cases,  since  the  latter  saponifies  and  is  then  ab- 
sorbed, thus  causing  a  re-excretion,  of  the  ether  with  its  attendant 
effects.  Olive  oil.  however,  raises  the  resistance  of  the  patient  by 
stimulating  phagocytosis  according  to  this  same  author  and  it  may 
be  used  per  rectum  in  6-ouiiee  doses  to  good  advantage. 

By  far  the  best.  and.  in  fact,  the  only  reliable  treatment  for  this 
condition,  is  gastric  lavage.  Its  use  on  the  operating  table  has 
already  been  mentioned.  Its  continued  use  after  the  patient  is 
awake  so  long  as  there  is  any  nausea  or  vomiting  in  those  permitting 
its  employment,  can  not  be  too  greatly  extolled.  It  is  self-evident 
that  some  irritating  substance  must  be  present  in  the  organ  if  the 
desired  result  is  to  be  obtained.  Often  a  carrying  out  of  the  pro- 
cedure not  only  relieves  the  actual  distress  .  of  the  symptom  itself, 
but  also  puts  an  end  to  the  anxiety  and  restlessness  which  so  com- 
monly are  manifested  by  these  sivfferers.  Especially  is  this  true  i1 
those  instances  where  the  stomach  has  a  tendency  to  dilate  and  be 
inactive.  In  the  cases  in  which  acute  dilatation  occurs  unfortunately 
this  symptom  is  less  marked,  the  general  appearance  of  the  patient, 
the  pulse  rate,  pain  in  this  region,  hiccough,  and  other  less  common 
symptoms  being  more  in  evidence.  It  is  needless  to  say  that  gastric 
lavage  under  such  circumstances  is  most  urgently  needed.  In  ad- 
dition a  hypodermic  of  pituitrin  (5  to  15  minims)  is  advisable. 

In  carrying  out  this  procedure  one  will  always  experience  more  or 
less  difficulty  with  the  patient.  The  fear  of  the  tube  and  the  dis- 
comforts it  entails,  especially  in  individuals  who  are  unaccustomed 
to  its  use,  are  not  to  be  treated  with  little  concern.  A  knowledge  of 
the  condition  of  the  heart  and  lungs  is  very  necessary,  and  most  of 
all,  the  confidence  of  the  patient  must  be  gained.  The  procedure 
should  be  explained  and  the  results  to  be  obtained  discussed  with 
the  patient,  and  his  cooperation  secured  before  any  attempt  is  made 
to  introduce  the  tube. 


44  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

He  is  then  raised  slightly  upon  pillows,  and  if  it  is  convenient, 
turned  on  his  side.  A  rubber  sheet  is  placed  over  the  bed  and  around 
his  neck,  the  sheet  extending  into  a  basin  on  the  floor.  A  towel  is 
kept  handy  for  the  operator  and  a  small  basin  for  the  patient  to  spit 
into.  In  some  very  nervous  individuals  it  is  advisable  to  spray  the 
pharynx  with  a  20  per  cent  solution  of  coeaine  in  order  to  allay  the 
gagging  during  the  passage  of  the  tube.  After  one  minute  the  co- 
caine is  spit  out  and  the  spraying  repeated  in  five  minutes,  as  ad- 
vised by  Ochsner,7  permitting  the  patient  to  swallow  a  little  of  the 
saliva  which  will,  to  a  certain  extent,  anesthetize  the  esophagus.  Poi- 
soning by  the  medicine  is  prevented  by  the  free  expulsion  of  the  saliva 
which  accumulates  in  the  mouth  during  the  administration. 

In  the  majority  of  cases  such  measures  are  unnecessary,  and,  as  a 
rule,  the  tube  is  inserted  without  any  such  elaborate  preparation. 

The  head  of  the  patient  is  grasped  l>y  the  operator,  which  maneuver 
not  only  supports  it.  but  allows  a  more  efficient  manipulation  of 
the  tube.  This  instrumenl  is  now  taken  from  a  basin  of  ice  where 
it  Avas  placed  at  the  beginning  of  the  procedure  and  the  patient 
is  asked  to  breathe  through  the  nose  and  to  give  undivided  at- 
tention to  the  admonitions  of  the  operator  who  will  ever  insist  that 
lie  keep  breathing  through  his  nose.  The  tip  of  the  tube  is  held  by 
the  operator's  hand  which  has  just  been  thoroughly  washed  (some 
use  rubber  gloves),  and  the  other  end  held  down  by  an  assistant  near 
the  basin  on  the  floor.  The  tube  is  now  gently  inserted  (without 
lubrication — some  use  glycerin)  straight  back  into  the  pharynx  and 
then  down  the  esophagus,  the  patient  in  the  meantime  being  asked  to 
swallow.  Once  in  this  organ  the  tube  is  pushed  rapidly  downwards 
until  the  white  line  on  it  is  reached  (depending  on  the  length  of  the 
patient,  of  course).  During  the  while  the  patient  is  being  reassured 
by  the  operator  and  continually  reminded  that  all  he  has  to  do  is  to 
breathe.  The  necessity  of  being  patient  and  kind  at  this  time  ever 
though  the  individual  suddenly  pulls  out  the  tube  is  to  he  impressed 
upon  the  operator,  since  once  the  patient  hums  lion-  to  lake  the  tube, 
no  further  difficulty  need  be  experienced,  and  the  impression  made 
during  the  first  insertion  will  usually  be  foremost  when  the  pro- 
cedure becomes  necessary  again  during  the  course  of  the  treatment. 
The  tube  is  now  brought  to  the  side  o\'  the  month  and  held  in  posi- 
tion while  an  assistant  fills  the  funnel  of  the  tube  with  cool  hydrant 
water  and  starts  the  siphonage. 

If  there  is  any  difficulty  in  getting  the  water  to  How,  the  tube  is 
rotated  and  it  is  either  pushed  further  in  or  pulled  out.  In  some 
cases  a  Politzer  bulb  has  been  used,  or  an  attached  bulb  is  employed 


EARLIEST    SUBJECTIVE    MANIFESTATIONS  45 

in  sucking  out  the  air,  which  maneuver  will  nearly  always  start 
the  flow ;  this  tube  integral  with  bulb,  however,  is  not  very  practical 
and  is  not  extensively  used  by  me. 

As  much  fluid  should  be  returned  as  is  poured  into  the  stomach; 
the  flow  is  frequently  started  and  kept  up  by  allowing  a  funnelful 
to  flow  in,  but  before  it  becomes  entirely  empty  lower  it  and  then 
pour  it  full  again,  the  maneuver  being  repeated  until  the  fluid  re- 
turns clear.  It  will  be  noted  that  the  patient  himself  frequently 
holds  the  tube  in  place  better  than  does  any  one  else.  With  proper 
training  and  care  with  patients  they  very  soon  learn  to  help  them- 
selves and  become  valuable  aids  to  the  operator.  In  such  instances 
one  person  alone  can  wash  any  stomach. 

The  stomach  should  be  washed  as  often  as  the  nausea  or  vomiting 
returns,  each  time  washing  until  the  fluid  returns  clear  if  it  takes 
considerable  water  to  accomplish  this  end,  so  long  as  the  patient  is 
not  too  exhausted.  The  tip  of  the  tube  should  have  more  than  one 
opening  which  will  often  prevent  blockage  either  by  contact  with 
the  stomach  wall  or  by  mucus. 

Kanavel8  employs  a  special  tube  by  means  of  which  continu- 
ous gastric  lavage  can  be  instituted  in  the  most  intractable  cases. 
I  heartily  concur  in  such  a  measure,  as  the  strain  of  having  the  tube 
inserted  is  done  away  with.  I  have  employed  this  method  in  a  few 
cases,  utilizing  the  ordinary  stomach  tube,  but  after  a  time  even  the 
most  phlegmatic  patient  tires  and  begs  to  have  the  tube  removed. 
Kanavel 's8  tube  is  smaller  and  more  suited  for  the  purpose  and 
should  be  tried  in  every  intractable  case,  especially  where  the  inser- 
tion of  the  tube  is  not  an  easy  procedure. 

It  has  long  been  taught  that  anesthetics  should  not  be  given  except 
in  the  presence  of  a  third  person.  The  reason  for  such  teaching  is 
supported  by  the  symptoms  exhibited  at  times  in  the  postoperative 
patient. 

Dreams. — It  is  common  knowledge  that  dreams  occasionally  occur 
during  the  anesthesia  which  are  honestly  believed  long  after  the  pa- 
tient has  recovered.  This  affords  a  chance  for  blackmail  or  other 
unpleasant  developments,  hence  measures  taken  to  thwart  such  pos- 
sibilities are  always  carried  out  by  the  wide-awake  operator.  The 
delusions  take  the  form,  particularly  in  neurotic  women,  of  an  idea 
that  a  sexual  advantage  has  been  taken  of  them  while  unconscious. 
It  should  be  added,  however,  that  not  only  do  these  nervous  women 
make  such  charges  at  times,  but  that  the  most  refined  phlegmatic 
women  have  been  guilty  of  the  same  statements. 

Mental  Aberration. — In  the  ae'ed  and  in  individuals  with  nerv- 


46  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

ous  instability  the  shock  of  an  operation  can  be  to  blame  for  more 
or  less  mental  aberration  which  may  suddenly  develop  during  the 
early  period  of  recovery.  It  has  been  said  that  this  is  due  further 
to  the  use  of  drugs  during  the  operation  or  in  the  early  after-care. 
Certainly  those  mental  disturbances  occurring  after  eye  operations  and 
which  are  mostly  hallucinatory  in  nature  are  due  to  this  cause  alone. 
Sajous5  states  that  "excluding  the  cases  due  to  shock,  nervous  strain, 
exhaustion,  and  drug  intoxication,  which  generally  appear  within 
the  first  twenty-four  hours,  it  is  probable  that  the  majority,  if  not 
all,  of  the  cases  of  postoperative  insanity  coming  on  within  the  first 
week  are  septic  in  origin."  That  it  should  occur  at  all  is  de- 
plorable, but  when  it  does,  the  shrewd  surgeon  will  have  been  forti- 
fied against  the  consequences,  and  will  be  left  unhampered  to  combat 
the  new  condition  as  best  he  knows  how.  For  suggestions  as  to  treat- 
ment, the  reader  is  referred  to  the  chapter  on  Postoperative  Psychoses. 

Complications  Arising  after  Local  Anesthesia. — The  complications 
arising  after  local  anesthesia  are  not  as  a  rule  nearly  so  many  or  so 
frequent  as  those  occurring  after  general  anesthesia.  The  nature  of 
the  complication  and  the  extent  of  its  severity  depend  upon  the 
operation  performed.  Since  practically  every  operative  procedure 
which  is  carried  out  under  general,  can  also  be  done  under  local, 
both  are  entitled  to  the  same  complications.  However,  the  latter  ap- 
parently entails  few  of  the  horrors  of  the  former,  and  it  is  generally 
conceded  that  the  postoperative  discomforts  and  risks  are  materially 
less,  particularly  the  dangers  of  pulmonary  disorders. 

The  after-care  for  the  ordinary  minor  operations  need  not  be  men- 
tioned, since  it  resolves  itself  practically  into  the  care  of  the  wound 
alone.  After  major  operations  the  same  systematic  care  is  exercised 
as  in  those  patients  who  have  been  given  ;i  general  anesthetic.  "With 
these  patients  who  have  had  a  local  anesthesia  sometimes  the  first 
complaint  is  nausea  which  often  develops  into  actual  vomiting.  This 
is  undoubtedly  due,  in  many  instance-;  to  tin1  morphine  so  generally 
given  before  operations.  The  same  efforts  put  forth  to  relieve  this 
condition  after  a  general  anesthetic  are  also  carried  out  here.  It  is 
here  not  so  necessary  to  exhibit  much  care  in  giving  fluids,  since  those 
are  nearly  always  taken  with  impunity,  even  when  the  stomach  is 
temporarily  upset  by  the  preceding  operative  maneuvers  a  few 
glasses  of  cool  water  will  not  only  clear  the  mucous  membrane  thor- 
oughly of  any  excessive  mucus  and  gastric  juice  which  had  been  se- 
creted, but  also  will  assist  in  giving  added  tone  to  the  musculature 
which  has  relaxed  during  the  period  of  mental  strain  and  distress 
while  the  patient   was  undergoing  the  actual  operation.     The  nausea 


EARLIEST    SUBJECTIVE    MANIFESTATIONS  47 

usually  does  uot  last  long  and  under  the  same  handling  that  is  af- 
forded the  general  anesthetic  patients  it  will  clear  up  in  a  very  short 
time. 

Pain  is  not  experienced  at  all  until  the  effects  of  the  anesthetic 
wear  off,  when  it  becomes  excruciating  at  times.  In  practically  every 
case  more  or  less  pain  is  experienced  in  the  wound,  and  measures 
are  taken  to  relieve  it  as  is  done  following  general  anesthesias.  Af- 
ter the  first  twenty-four  hours  it  becomes  less  and  less,  morphine 
being  rarely  necessary  after  this  period.  The  edema  and  induration 
about  the  wound  last  longer  because  of  the  foreign  material  injected 
at  the  operation,  and  for  this  reason  most  attention  is  paid  to  the 
wound  itself.  In  order  to  alleviate  this  as  much  as  possible,  I  em- 
ploy pure  glycerin  directly  over  the  wound  after  the  first  twenty-four 
hours,  the  dressings  being  kept  moist  with  this  chemical  for  several 
days,  or  at  least  until  the  swelling  and  induration  have  been  de- 
creased to  a  minimum.  Glycerin  is  not  only  a  hydroscopic  agent, 
but  also  is  slightly  antiseptic  and  such  wounds  kept  bathed  in  it  sel- 
dom develop  in  my  experience  the  "fiery  swollen  appearance"  seen 
occasionally  after  local  anesthesia.  It  should  also  be  cautioned  that 
this  treatment  extending  over  too  long  periods  of  time  will  cause  a 
papulovesicular  eruption  around  the  wound  edares  which  predis- 
poses to  infection,  and  just  as  soon  as  this  occurs  the  glycerin  must 
be  discontinued  regardless  of  the  condition  of  the  deep  tissues  in 
close  proximity  of  the  wound. 

Immediately  after  the  operation  if  it  has  been  an  extensive  one, 
the  patient  will  express  a  sigh  of  relief  and  rejoice  at  the  prospect 
of  going  back  to  bed.  Once  here,  it  will  be  only  too  evident  that 
he  is  tired  out  from  the  strain,  which  practically  all  patients  un- 
dergo, and  will  welcome  sleep. 

It  may  be  necessary  to  massage  his  strained  and  bruised  muscles 
or  at  least  give  an  alcohol  rub  in  addition  to  making  the  patient  com- 
fortable by  placing  his  pillows  properly  and  putting  hot-water  bot- 
tles around  hini  ('always  bearing  in  mind  the  possibility  of  burn- 
ing him).  "When  his  discomforts  are  relieved,  the  room  is  darkened, 
all  visitors  excluded,  and  the  patient  encouraged  to  relax,  refrain 
from  talking,  and  attempt  to  lose  himself  in  sleep.  If  the  exhaustion 
has  not  been  too  great,  sleep  will  come  shortly  if  precautions  have 
been  taken  to  have  the  bed  and  room  prepared  as  is  ordinarily  done 
for  patients  who  take  a  general  anesthetic.  The  rest  which  he  thus 
secures  will  do  more  to  alleviate  the  suffering  of  the  worn-out  body 
and  mind  than  will  any  drug.  Morphine  in  small  doses  is  given  to 
prevent  possible  pain  in  the  wound  disturbing  him  during  this  period 


48  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

of  slumber.  As  a  usual  thing  these  patients  will  go  to  sleep  without 
any  medication,  but  occasionally  one  is  not  so  favored.  It  is  a  good 
rule  to  give  with  the  proctoclysis  30  to  60  grains  sodium  bromide, 
to  every  nervous  patient,  and  to  this  may  be  added  at  times  25  to  30 
grains  chloral  hydrate.  An  ice  bag  over  the  fast  and  palpitating 
heart  in  neurotic  patients  will  do  much  to  quiet  this  organ  and  allow 
rest  and  perfect  recuperation. 

Light  nourishment  in  any  form  suggested  by  the  patients  is  to  be 
allowed  at  a  very  early  period.  Its  importance  is  second  to  that  of 
sleep  only  as  a  means  of  quieting  and  restoring  the  individual  who 
has  just  experienced  an  operation  under  local  anesthesia. 

Bibliography 

iMurphy:      Practitioner's    Encyclopedia    of    Medicine    ami    Surgerv,    1915,    p. 

504. 
zFinney:     Address,  The   Significance  and  Effect   of  Pain.  Oct.   6.   1914. 
3Halperin:     New  York  Mel.  Jour..  July.   1911. 
•»Luke:     Guide  to  Anesthetics,   1 '."•''>.   ]•.  '.'4. 
5Sajo.ua:     Analytic  Cyclopedia  of   Practical  Medicine,  1916,  iv.  668. 

Ferguson:     New  York  Med.  Jour..  June.  1912. 
"Ochsner:     Quoted  by  Crandon:     Surgical  After  Treatment,  1909,  p.  33. 
sKanavel:     Surg.,  Gynec.  and  Obst.,  Oct..  1! 


CHAPTER  VII 

LATER  SUBJECTIVE   SYMPTOMS 
By  Willard  Bartlett,  St.  Louis,  Mo. 

The  patient  has  recovered  full  consciousness  and  though  his 
"earliest  subjective  symptoms"  may  still  be  present,  he  now  be- 
gins to  manifest  certain  conditions  which  are  directly  attributable 
to  the  manipulation  to  which  he  was  subjected  while  still  on  the 
operating  table  or  during  the  period  of  returning  consciousness. 
They  cause  at  times  no  little  irritation  and  annoyance  to  the  patient. 
Such  accidents  happen  in  the  hands  of  the  most  careful  surgeon  or 
of  the  best  surgical  teams,  and  apparently  can  not  always  be  avoided, 
which  fact  makes  their  occurrence  none  the  less  deplorable.  The  sur- 
geon's embarrassment  in  many  instances  is  intensified  by  the  pros- 
pect of  a  damage  suit,  a  phase  of  the  matter  which  should  not  be  too 
lightly  passed  over  by  him. 

Ether  Conjunctivitis. — Ether  conjunctivitis  is  rapidly  becoming  a 
very  uncommon  accident,  a  fact  which  is  indeed  welcome  to  both  the 
profession  and  the  laity  alike.  This  complication  has,  in  my  experi- 
ence, always  produced  more  suffering  than  has  the  wound  coexistent 
with  it.  This  is  particularly  true  in  all  cases  where  the  eyes  were 
not  irrigated  immediately  upon  the  entrance  of  the  ether.  I  have 
most  frequently  observed  it  when  the  eyes  were  covered  with  rub- 
ber, gutta  percha  or  other  similar  impervious  materials.  A  drop  of 
ether  or  even  ether  vapor  which  once  gets  under  such  a  covering  is 
held  confined  there  and  much  damage  done  in  consequence. 

The  results  of  this  accident  are  usually  complained  of  next  day 
when  the  patient  notes  a  smarting  and  burning  in  the  eye  affected. 
On  examination  one  will  find  an  active  hyperemia  of  the  conjunctiva, 
the  vessels  being  prominent  and  the  palpebral  conjunctiva  being 
more  vascular  than  usual.  Other  portions  of  the  conjunctiva  become 
involved  later.  The  lids  become  swollen  and  in  the  most  severe  cases 
the  conjunctival  sac  may  fill  with  pus.  Under  proper  treatment  the 
condition  does  not  extend  beyond  a  simple  catarrhal  inflammation 
and  its  duration  is  short.  Cases  with  more  extensive  involvement 
should  at  once  be  turned  over  to  an  oculist,  as  the  danger  of  corneal 
ulcer  is  imminent.  Careful  examination  of  the  eyes  in  patients  suf- 
fering  from   ether   conjunctivitis   can   not   be   too    strongly   insisted 

49 


50  AFTER-TREATMENT    OP    SURGICAL   PATIENTS 

upon.  I  had  a  patient  of  this  kind  threaten  malpractice  suit  at  a  re- 
mote period,  claiming  that  my  carelessness  had  resulted  in  a  corneal 
ulcer.  To  be  sure  a  scar  could  hi'  seen  and  the  thing  was  not  disposed 
of  until,  by  mere  good  fortune.  I  happened  onto  the  oculist  wlco 
had  treated  her  corneal  ulcer  previous  to  our  operation. 

The  treatment  is  first  and  always  preventive.  All  trained  anes- 
thetists have  individual  methods  of  protecting  the  eyes  during  the 
etherization.  Personally  I  have  not  had  one  complaint  after  many 
thousand  anesthesias  in  which  the  Ferguson  mask  has  been  used 
and  the  eyes  of  the  patient  left  uncovered. 

If  there  is  any  reason  to  believe  that  ether  has  come  in  contact 
with  the  eye.  I  would  advise,  as  Crandon1  already  has  before  me,  that 
the  eye  be  irrigated  at  once  with  a  little  warm  water,  physiologic  salt, 
or  2  per  cent  boric  acid  solution.  I  have  on  more  than  one  occasion 
seen  a  drop  of  ether  fall  directly  into  the  eye,  but  never  heard  a 
later  complaint  where  it  was  followed  in  a  few  seconds  by  irrigation 
with  any  of  the  above  liquids  or  a  drop  of  sterile  olive  oil.  This 
lubricant,  particularly,  should  be  kept  in  the  operating  room. 

When  the  condition  occurs  in  spite  of  the  measure  suggested  above, 
the  eyes  are  irrigated  twice  a  day  with  2  per  cent  boric  acid  solu- 
tion and  the  eyes  protected  from  the  light  glare,  either  by  smoked 
glasses,  eye  shields  or  keeping  the  window  shades  down. 

During  the  early  stages  one  may  employ  with  advantage  Posey's2 
technic  which  is  carried  out  as  follows:  "Several  pads  of  gauze  of 
three  or  four  thicknesses,  about  the  size  of  a  silver  dollar,  are  laid  on 
a  block  of  ice.  The  ice  should  be  suspended  in  a  receptacle  with  per- 
forations in  iis  bottom,  which  will  permit  the  water  and  any  secretion 
from  the  compress  to  drain  off  into  a  jar  beneath  it.  An  ordinary 
kitchen  colander  and  washbasin  will  answer  very  well  for  this  ap- 
paratus. One  of  the  pads  is  taken  from  the  ice  as  soon  as  it  lias  been 
saturated  and  is  applied  to  the  closed  lids,  removed  in  a  few  mo- 
ments and  a  fresh  one  substituted  for  it.  Compresses  of  absorbent 
cotton  which  have  been  soaked  in  ice  water  may  also  be  employed. 
They  should  lie  squeezed  out  sufficiently  to  prevent  any  of  the  water 
trickling  over  the  patient's  face  and  neck."  The  compresses  should 
not  be  continued  over  twenty-four  hours,  and  applied  every  other 
hour.  The  danger  is  devitalization  from  the  cold  which  may  result 
in  corneal  ulcer. 

Dry  Mouth.  -  -The  association  of  dry  mouth  with  general  thirst 
on  awakening  from  an  anesthesia  is  so  intimate  that  the  condition 
has  already  been  discussed  under  this  head.  There  is.  however,  an- 
other phase  to  this  subject  which  requires  further  attention  than  has 


LATER   SUBJECTIVE    SYMPTOMS  51 

hitherto  been  given  to  it.  I  refer  to  the  management  of  the  patient 
while  still  under  the  influence  of  the  anesthetic  or  during  the  sleep 
resulting  from  the  preanesthetic  drug.  It  is  my  observation  that  an 
otherwise  attentive  and  capable  nurse  will  allow  an  unconscious  pa- 
tient to  breathe  with  the  mouth  wide  open  and  not  make  an  attempt 
to  prevent  the  mucosa  becoming  as  dry  as  the  skin  outside.  This 
can  be  prevented  by  the  simple  maneuver  of  keeping  the  orifice 
covered  by  a  few  layers  of  loose-mesh  gauze  which  are  frequently 
moistened  in  a  solution  of  glycerin  and  water  of  equal  parts. 

Dry  mouth  occurring  later  on  in  the  convalescence  and  not  caused 
by  a  general  loss  of  body  fluids  during  the  operative  procedure  or 
an  insufficient  intake  after  the  operation  may  be  caused  by  disease 
of  the  salivary  glands  or  of  the  duets,  or  of  both.  It  may  also  occur 
as  a  local  result  of  the  operation  itself.  A  recent  case  illustrates 
this  point  quite  well.  I  removed  a  carcinoma  from  the  floor  of  an 
elderly  gentleman's  mouth  and  in  the  course  of  the  operation  de- 
stroyed all  the  salivary  ducts  in  this  region.  By  the  time  healing 
was  complete,  his  complaint  of  dry  mouth  was  most  insistent.  Chew- 
ing gum,  slippery  elm.  and  other  remedies  were  tried  in  vain  until 
I  hit  upon  the  idea  of  a  film  of  mineral  oil  (petrolatum  liquidum) 
as  a  substitute  for  saliva.  The  result  was  astonishingly  good; 
so  much  so  that  the  patient  when  seen  a  year  later  extracted 
a  tiny  bottle  from  his  pocket  with  the  remark,  "My  mouth  never 
gets  dry  as  long  as  I  carry  this  and  take  a  few  drops  of  oil  every 
hour  or  two." 

The  treatment  of  this  condition  in  addition  to  that  suggested  above 
consists  first  in  finding  the  cause.  This  is  usually  the  result  of  in- 
sufficient fluids  in  the  body  and  is  remedied  by  increasing  the  in- 
take as  already  described.  In  the  meantime  the  mouth  is  frequently 
rinsed  with  cool  water,  or  a  cool  sponge  wet  with  this  medium  is  re- 
tained. Another  may  be  applied  over  the  lips.  If  the  inside  of  the 
mouth  becomes  stagnant  due  to  improper  cleanliness  on  the  part  of 
the  patient  from  any  cause,  it  is  cleaned  frequently  by  the  nurse  with 
a  swab  of  gauze  saturated  in  4  per  cent  boric  acid  solution.  In  ad- 
dition, once  or  twice  daily  olive  or  mineral  oil  may  be  applied  in 
the  same  manner. 

Painful  Tongue. — The  tongue  may  become  affected  independent 
of  a  dry  mouth,  and  in  fact  most  often  gives  trouble  in  those  cases 
where  some  manipulation  of  this  organ  was  necessary  during  the 
course  of  the  operation.  It  is  necessary  as  a  matter  of  course  that 
the  tongue  be  held  forward  during  the  course  of  many  general  anes- 
thesias to   facilitate  respiration.     If  this  be   done  with   a   crushing 


52  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

forceps,  so  much  pain  and  swelling  are  caused  for  a  few  days  that 
the  patient  may  suffer  more  in  consequence  of  such  maltreatment 
than  he  does  from  the  surgical  wound  itself.  Considerable  pain 
will  be  produced  even  though  such  clamps  are  not  used  but  instead 
instruments  especially  devised  for  this  purpose  such  as  the  Carmalt 
forceps.  The  painful  after-effects  should  be  considered  at  the  time 
of  the  manipulation,  and  these  so  far  as  possible  mitigated  by  a  more 
refined  and  humane  manner  of  handling  this  sensitive  structure. 

The  anesthetist  who  grasps  the  tongue  with  a  gauze  strip  held  be- 
tween the  thumb  and  forefinger  probably  does  not  damage  it  at  all. 
There  are  many  case  in  which,  however,  such  gentle  measures  do  not 
suffice,  here  I  recommend  the  transverse  insertion  near  the  tip,  of 
a  slender  thread  carried  by  a  fine  needle.  This  is  far  better  than 
the  tenaculum  used  by  some  anesthetists,  which  is  in  turn  vastly  to 
be  preferred  to  a  crushing  instrument. 

The  treatment  is  simply  palliative.  The  mouth  and  teeth  are  kept 
clean  with  some  antiseptic  mouth  wash  such  as  liquor  antisepticus 
alkolinus,  4  per  cent  boric  acid  or  Dobell's  solution  (diluted  one- 
half  its  strength).  Potassium  chlorate,  saturated  solution,  or  po- 
tassium permanganate  1  :4000  may  be  employed  if  the  condition  does 
not  speedily  clear  up.  It  may  be  necessary  to  hold  ice  on  the  swollen 
tongue  for  the  first  clay  or  so.  I  have  never  seen  this  necessary  as 
the  warm  mouth  washes  were  sufficient  in  every  case.  Silver  nitrate 
in  10  per  cent  to  20  per  cent  solution  may  be  used  directly  on  the 
lesion  if  it  is  slow  in  healing  and  one  of  the  stronger  mouth  washes 
employed  several  times  a  day. 

For  any  injury  of  the  tongue  during  convalescence  the  treatment 
is  the  same  as  the  above  unless  it  is  so  extensive  that  surgical  inter- 
ference is  necessary  to  control  hemorrhage.  One  patient  came  under 
my  observation  who  accidentally  fell  on  the  tenth  postoperative  day. 
Avhile  attempting  to  walk  to  the  bathroom;  she  struck  her  chin  and 
nearly  bit  her  tongue  in  two.  Several  stitches  were  taken  without 
an  anesthetic,  and  a  potassium  chlorate  mouth  wash  used  three  times 
a  day  for  six  days,  when  the  wound  had  healed.  A  warm  boric  acid 
wash  was  used  for  a  week  longer,  during  which  time  all  soreness  and 
other  inconvenience  completely  disappeared. 

In  the  presence  of  this  complication  it  is  best  to  give  the  least  ir- 
ritating foods,  particularly  those  soft  and  warm  and  free  from  high 
seasoning.  In  some  severe  cases,  as  in  the  one  mentioned,  the  food 
may  be  given  in  liquid  form  through  the  nose  for  a  few  days. 

Sore  Jaw. — A  sore  jaw  is  one  of  the  disagreeable  experiences 
which  sometimes  go  together  to  make  up  a  never-to-be-forgotten  pie- 


LATER    SUBJECTIVE    SYMPTOMS  53 

ture,  when  surgical  treatment  has  not  been  judiciously  managed. 
It  is  now  and  then  necessary  during,  as  well  as  after,  a  difficult  anes- 
thesia, to  hold  the  jaw  forward  in  order  that  the  muscles  running 
from  the  symphysis  to  the  hyoid  bone  may  hold  the  pharynx  open. 
This  is  commonly  done  with  the  fingers  hooked  around  the  ascending 
ramus  just  above  the  angle,  and  very  slight  damage  is  done  provided 
the  pressure  is  not  too  long  maintained,  unless  the  tips  of  the  fingers 
are  carelessly  allowed  to  slip  too  far  around  the  bone  and  infringe 
upon  the  deep  structures  of  the  neck. 

Under  such  circumstances  an  effect  is  produced  very  similar  to 
that  for  which  the  jiujitsu  wrestler  strives,  and  the  patient  is  caused 
undue  suffering  in  consequence.  The  procedure  can  be  varied  from 
time  to  time  with  advantage  for  the  patient  as  well  as  for  the  anes- 
thetist by  hooking  the  index  finger  over  the  incisor  teeth  and  the 
thumb  of  the  same  hand  under  the  symphysis  and  pulling  instead 
of  pushing  the  mandible  forward. 

The  treatment  in  addition  to  the  preventive  measure  stated  above 
is  palliative.  The  condition  usually  disappears  in  a  day  or  so ;  it  is, 
however,  not  always  best  to  await  a  favorable  outcome,  but  to  insti- 
tute some  measure  of  relief  at  once.  Probably  massage  is  the  best 
remedy  at  our  command,  this  performed  for  twenty  minutes  twice 
a  day  will  help  clear  up  the  worst  cases  of  this  nature.  Various 
counterirritants,  such  as  turpentine  or  some  liniment  whose  princi- 
pal ingredient  is  chloroform  or  ammonia,  will  also  prove  efficient  in 
the  patient's  mind  at  least.  The  external  application  of  heat  may 
be  tried  on  those  cases  where  no  application  of  drugs  is  made. 

Sore  Throat. — Sore  throat  is  particularly  likely  to  follow  any 
operation  in  which  there  has  been  manipulation  of  the  trachea, 
larynx,  etc.  "We  note  it  most  commonly  after  thyroidectomy.  It 
may  be  prevented  in  many  patients  by  placing  them  in  bed  flat  on 
the  face,  with  a  pillow  under  the  chest  immediately  after  the  opera- 
tion and  leaving  them  in  this  posture  for  several  hours  or  until  it  be- 
comes intolerable.  A  moment's  reflection  will  convince  any  one  that 
downhill  drainage  of  the  respiratory  passages  is  secured  in  this  man- 
ner ;  in  fact  a  surprising  amount  of  mucus  and  saliva  runs  out,  which 
in  any  other  position  would  tend  to  fill  up  the  bronchial  tree,  and  re- 
quire, in  my  experience,  some  days  to  be  coughed  up. 

Nothing  else  has  compared  in  my  hands  with  the  inhalation  of  steam 
for  the  relief  of  surgical  sore  throat.  Many  other  remedies  have 
been  proposed,  and  tried  by  us,  only  to  be  discarded.  Some  of  our 
patients  seem  to  gain  a  measure  of  relief  from  holding  ice  in  the 


54  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

mouth,  and  others  from  gargling  a  mild  alkaline  solution.     The  steam 
is,  however,  practically  unfailing-  in  its  effect. 

Painful  Respiration. — Painful  respiration  is  a  serious  matter  he- 
cause  it  often  influences  the  patient  to  protect  himself  by  limiting 
the  respiratory  excursion,  with  imperfect  hum'  ventilation  and  pneu- 
monia as  a  consequence.  This  train  of  undesirable  events  is  prone 
to  follow  the  making  of  wounds  low  on  the  chest  wall  or  high  on  the 
abdominal  wall;  especially  is  this  true  if  such  wounds  are  unduly 
tender  in  consequence  of  inflammatory  changes.  It  may  also  he 
caused  by  violent  use  of  the  diaphragm,  as  in  vomiting-  or  the  chest 
wall  may  have  become  injured  as  a  result  of  artificial  respiration  or 
careless  handling,  while  removing  the  patient  to  bed,  etc.  The  pres- 
sure of  extensive  gauze  packing,  or  of  clamps  left  hanging  on  the 
tissues  near  the  diaphragm  constitutes  an  added  risk. 

Little  is  to  be  feared  from  an  intelligent  patient  who  will  sit  up 
in  bed  and  inspire  deeply  a  few  times  every  hour  no  matter  how  much 
it  hurts,  but  the  treatment  becomes  quite  another  matter  when  chil- 
dren or  adults  of  kindred  mental  attitude  are  concerned. 

I  have  had  no  trouble  with  such  an  individual  provided  only  1 
could  get  him  interested  in  the  attempt  to  score  a  higher  record 
than  his  nurse  when  blowing  into  a  tube  connected  with  a  mercury 
manometer.  Of  course  no  forceful  expiration  is  possible  unless  pre- 
ceded by  a  correspondingly  deep  inspiration,  hence  the  value  of  this 
little  subterfuge  becomes  apparent  at  once.  The  mercury  goes  higher 
every  hour,  the  increase  in  distance  being  a  matter  of  astonishment 
to  the  one  who  observes  it  for  the  firsl  time.  There  are,  as  a  matter 
of  course,  surgical  patients  who  are  too  ill  for  this  sort  of  treatment. 
In  these  only  those  measures  which  fulfil  the  individual  requirements 
can  lie  instituted. 

Painful  respiration  is  caused  in  most  instances  by  pleurisy,  but 
in  making  the  diagnosis  of  the  condition  the  factors  mentioned 
above  must  be  seriously  considered  and  the  probabilities* of  an  inter- 
costal neuralgia  or  actual  bruising  of  the  muscular  or  other  tissues 

must  be  considered. 

Schepelmann3  states  that  in  dry  pleurisy,  especially,  the  pain  is  in- 
creased on  bending  the  body  towards  the  well  side,  while  in  inter- 
costal neuralgia  there  is  more  pain  when  the  body  is  bent  towards 
the  affected  side. 

Treatment  consists  in  first  utilizing  the  apparatus  mentioned 
above,  and  the  patient  is  encouraged  to  bear  with  the  discomfort 
for  a  few  hours  at  least.     Usually  the  condition   improves  steadily 


LATER    SUBJECTIVE    SYMPTOMS  55 

from  the  first  efforts  at  treatment  and  no  further  measure  is  nec- 
essary. 

If  there  are  symptoms  necessitating  more  radical  measures  as  is 
seen,  for  instance  in  beginning  pleurisy  at  times,  dry  cupping  is 
resorted  to  at  once  and  kept  up  twice  each  day  until  the  distress  has 
ameliorated.  Strapping  the  chest  is  resorted  to  when  cupping  is 
not  employed,  but  this  latter  maneuver  has  never  given  the  relief 
so  far  as  I  have  observed,  that  may  be  accredited  to  the  former. 

The  cases  of  intercostal  neuralgia  may  require  more  than  putting 
the  side  at  rest  by  means  of  adhesive  straps.  When  the  pain  is  per- 
sistent, even  in  the  face  of  such  treatment,  it  may  be  necessary 
in  a  few  rare  cases  to  inject  the  nerve  itself  with  a  mixture  first 
brought  to  my  notice  by  V.  P.  Blair.  This  consists  of  novocaine,  10 
gr.,  chloroform,  20  minims,  alcohol  6  drams,  to  which  freshly  dis- 
tilled water  is  added  until  one  ounce  of  the  mixture  is  obtained.  It 
is  injected  into  the  nerve  sheath  by  means  of  a  very  fine  needle.  The 
relief  is  said  to  be  instantaneous.  In  carrying  out  this  operation  the 
patient's  mental  attitude  is  to  be  considered,  as  the  distress  which 
it  causes  is  so  great  occasionally  as  to  even  preclude  its  use.  In 
such  cases  it  will  usually  be  found  that  the  pain  can  be  eliminated 
by  the  other  simpler  means.  In  true  neuralgias,  however,  the  pa- 
tient will  not  object  to  the  treatment,  especially  if  the  area  of  in- 
jection is  first  anesthetized  with  a  little  %  per  cent  novocaine. 

Localized  soreness,  not  a  pleurisy  or  an  intercostal  neuralgia,  is 
best  treated  by  massage.  Hot  applications  in  the  form  of  the  tur- 
pentine stupe  or  hot-water  bag  are  also  useful.  Liniments  as  em- 
ployed for  sore  jaw  may  be  applied  where  the  hot  water  applica- 
tion is  not  practical. 

Anesthesia  Paralysis. — Anesthesia  paralysis  is  usually  not  a  per- 
manent affliction,  though  a  particularly  distressing  one  and  pos- 
sessed of  a  medicolegal  aspect.  This  complication  is  due  only  indirectly 
to  the  anesthetic.  The  injury  itself,  which  results  in  functional  loss 
to  the  various  nerves  of  the  body,  may  be  produced  by  the  position 
of  the  patient  on  the  operating  table  or  pressure  on  localized  parts 
of  his  anatomy. 

Probably  the  most  common  etiologic  factor  is  the  careless  practice 
of  many  anesthetists  of  allowing  an  unconfined  flaccid  arm  to  drop 
down  and  hang  for  a  time  over  the  edge  of  the  operating  table. 
Such  treatment  frequently  causes  extensive  pressure  to  be  exerted 
upon  the  musculospinal  nerve  while  the  brachial  plexus  is  also  a 
frequent  sufferer  from  mechanical  injuries  during  anesthesia,  this 
being  apparently  more  often  affected  than  is  any  individual  nerve. 


56  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

Its  frequent  occurrence  in  women  compared  to  men  causes  Molinari4 
to  state  that  women  seem  more  predisposed  to  this  complication. 

The  injury  to  the  plexus  is  produced  in  a  variety  of  ways.  No 
doubt  the  most  common  method  is  the  extension  of  the  arms  above  the 
head  as  is  so  often  seen  during  the  use  of  the  Trendelenburg  posi- 
tion. The  actual  condition  as  stated  by  Budinger3  reveals  that  dur- 
ing such  a  maneuver  the  trunks  of  the  plexus  are  pinched  between 
the  clavicle  and  the  first  rib  at  the  point  where  these  cross  the  rib. 
By  further  extending  the  arms  the  clavicle  rotates  upon  its  trans- 
verse axis  until  in  the  most  extreme  extension  the  posterior  superior 
border  becomes  the  inferior  posterior,  thereby  limiting  still  more  the 
area  between  the  two  bones  and  particularly  compressing  the  upper 
and  posterior  cords  of  the  plexus.  In  his  discussion  of  this  subject 
he  further  calls  attention  to  the  fact  that  in  some  patients  there  is 
a  peculiar  formation  of  the  clavicle  and  thorax  which  permits  of 
an  increase  in  pressure  during  this  position.  He  also  found  that  by 
bringing  the  head  towards  the  side  of  the  abducted  arm  the  corre- 
sponding nerves  escaped  compression  by  slipping  outwards  and  from 
beneath  the  clavicle.  Drawing  the  head  to  the  opposite  side  did  not 
produce  these  same  results. 

Other  German6  authors  believe  that  compression  by  the  transverse 
processes  of  the  vertebra  of  the  fifth  and  sixth  cervical  nerves  as 
they  leave  the  spinal  column  is  a  common  cause  of  brachial  plexus 
paralysis.  Such  an  accident  is  likely  to  occur  they  state  when  the 
arms  are  extended  over  the  head  during  anesthesia. 

Postoperative  paralysis  may  result  from  temporary  pressure  of 
the  head  of  the  humerus  on  the  brachial  plexus  below  the  clavicular 
portion  following  hyperelevation  of  the  arm  over  the  head  with  ro- 
tation inward  according  to  Glitsch.7  The  median  nerve  is  partic- 
ularly liable  to  injury  as  it  passes  over  the  head  of  the  humerus  in 
this  instance,  then  while  bending  the  elbow  and  rotating  the  arm  out- 
wards, the  ulnar  nerve  is  exposed  to  injury.8  Traction  on  the  plexus 
can  be  brought  about  by  various  faulty  positions  of  the  arm  during 
operations  upon  the  breast,  shoulder  joint,  etc.,  also  in  such  in- 
stances the  actual  operative  procedure  is,  of  course,  a  matter  to  be 
taken  into  consideration. 

Paralysis  of  all  the  nerves  of  both  arms  have  been  reported.  Bern- 
hart8  notes  such  an  instance  where  the  arms  were  maintained  above 
the  head  during  a  Trendelenburg  position  for  one  and  one-half  hours. 
Halstead0  also  observed  such  a  case  in  the  practice  of  one  of  his 
friends.  I  also  once  saw  a  double  palsy  follow  an  operation  in  which 
both  hands  were  firmly  held  above  the  patient's  head  during  an 
operation  of  long  duration.     The  malady  lasted  more  than  a  year  on 


LATER   SUBJECTIVE    SYMPTOMS  57 

one  side  and  several  months  on  the  other.  In  the  case  observed  by 
Halstead9  the  paralysis  disappeared  within  one  year.  Such  experi- 
ences tend  to  make  the  observer  uncomfortable  whenever  he  sees 
the  upper  extremities  so  treated  in  the  course  of  an  operation  which 
might  be  equally  as  well  performed  with  them  at  the  patient's  sides. 

Paralysis  may  result  from  pressure  on  any  motor  nerve  in  the 
body.  Flateau10  reported  a  case  of  bilateral  facial  paralysis  follow- 
ing pressure  of  the  anesthetist's  fingers.  Injuries  to  various  tho- 
racic nerves  may  result  from  the  position  of  the  patient.  Halstead9 
says  "that  the  lateral  or  lateroprone  position  maintained  over  too 
long  a  period  may  be  instrumental  in  producing  compression  of  the 
brachial  plexus,  trunks,  and  individual  nerves,  the  circumflex  and 
radial  being  particularly  exposed  to  danger.  The  popliteal  and 
other  nerves  of  the  legs  are  also  liable  to  injury  from  pressure  of  the 
table  during  the  Trendelenburg  position.  The  patient  often  hangs 
with  all  the  weight  borne  by  the  lower  legs  unless  shoulder  crutches 
are  used.  In  strapping  the  thighs  preparatory  to  an  anesthesia  the 
possibility  of  nerve  injury  exists  unless  slight  pressure  be  employed. ' ' 

"The  rarity  of  any  similar  lesion  in  the  lower  extremity  coupled 
with  the  observation  that  arms  are  frequently,  and  legs  seldom,  sub- 
jected to  the  strain  of  most  unusual  positions  on  the  table,  leads  to 
the  obvious  conclusion  that  the  upper  extremities  should  always  be 
rather  loosely  confined  at  the  recumbent  patient's  sides  when  the 
execution  of  the  operation  is  not  hindered  thereby.  To  be  sure,  there 
are  conditions  of  anesthesia,  under  which  the  necessary  handling  of 
a  patient  becomes  so  difficult  as  to  leave  the  attendants  little  choice 
as  to  just  how  the  arms  should  be  held ;  while  on  other  occasions  the 
necessity  of  keeping  some  unusual  operative  field  exposed  may  pre- 
clude the  possibility  of  an  easy  position  for  both  shoulder  regions. 
Under  such  circumstances,  of  course,  the  surgeon  can  only  accept 
the  better  of  the  two  possibilities  and  hasten  the  operative  work  as 
much  as  consistent  with  thoroughness." 

"The  mechanical  factors  involved  in  these  cases  are  in  each  case 
so  prominent  and  our  efforts  to  eliminate  them  so  strenuous  that 
other  causes  of  the  same  condition  are  almost  overlooked.  It  has 
been  considered  especially  by  a  few  French  observers  that  the  ether 
itself  through  its  toxic  action  on  the  nerves,  lowers  the  resistance  to 
trauma,  which  predisposes  to  the  paralysis.  The  condition  was  more 
common  in  the  days  of  chloroform  anesthesia  and  would  occur  days 
and  even  weeks  after  its  administration.  Molinari4  does  not  consider 
the  theory  tenable,  nor  in  view  of  the  evidence  in  favor  of  mechanical 
injury  would  we  consider  that  the  anesthetic  played  a  very  important 
role  in  the  actual  production  of  the  malady.     The  fact  that  paralyses 


58  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

occur  so  long  after  the  operation  gave  color  to  the  French  contention, 
but  at  times  exactly  the  same  phenomena  occur  following  any  anes- 
thesia." 

Halstead9  to  whom  we  owe  so  much  considers  a  central  paralysis 
which  may  occur  during  the  administration  of  a  general  anesthetic. 
He  states  that  the  condition  is  rare  and  that  we  have  little  direct 
evidence  as  to  the  cause  of  the  disease.  Two  hypotheses  he  says  are 
to  be  considered:  "First,  that  the  lesion  is  due  to  ischemic  soft- 
ening, following  a  hemorrhage.  Secondly,  that  there  is  a  primary 
degeneration  the  result  of  toxic  action  of  the  anesthetic  upon  the 
cerebral  cortex.  When  hemorrhage  is  the  cause  of  the  paralysis,  we 
must  assume  an  existing  sclerosis  of  the  vessels,  which  give  way  usu- 
ally during  the  stage  of  excitation  of  ether  narcosis."  Instances  of 
this  latter  accident  have  occurred  more  often  than  the  former.  Many, 
no  doubt,  have  accredited  it  to  the  narcosis  when  the  condition  would 
have  come  about  had  this  not  been  attempted.  Buxton11  noted  two 
patients  in  whom  this  happened  previous  to  the  operation.  Others 
have  also  called  attention  to  this  malady  in  the  instructions  given 
for  the  preparative  care  of  their  patients. 

It  is  possible  that  a  previously  deranged  nervous  system  does  play 
a  role  in  predisposing  to  paralysis,  as  witnessed  by  the  fact  that  I 
recently  observed  a  marked  brachial  palsy  affecting  a  highly  neurotic 
individual  who  was  carefully  watched  during  the  anesthesia,  and 
who  experienced  none  (to  our  knowledge  at  least)  of  the  ordinary 
exciting  factors  common  in  these  cases.  He  had  a  syphilitic  history, 
as  it  appeared  to  me. 

The  treatment  concerns  itself  first  with  the  prevention  of  the  mal- 
ady. If  this  is  kept  in  mind  during  the  arranging  of  the  patient  on 
the  operating  table,  there  need  be  slight  fear  as  to  a  good  outcome. 
I  never  allow  the  arms  to  be  drawn  above  the  head  for  any  opera- 
tion. In  instances  where  the  Trendelenburg  position  is  used,  care- 
fully and  thickly  padded  shoulder  crutches  are  employed.  For 
breast  operations  the  arm  n-sts  comfortably  on  a  padded  support 
placed  at  right  angles  to  the  body.  For  every  other  operation  the 
patient  is  carefully  observed  to  make  sure  that  there  is  sufficient 
padding  under  the  parts  exposed  to  pressure  and  a  position  assumed 
most  comfortable  to  him  and  at  the  same  time  least  objectionable  to 
the  surgeon.  No  one  allows  a  leg  or  an  arm  to  hang  unsupported  in 
this  day  of  preventive  medicine.  Careful  study  of  the  patient,  lead- 
ing to  a  thorough  knowledge  of  the  condition  of  his  nervous  and  vas- 
cular systems,  will  insure  measures  to  correct  abnormal  conditions 
and  thus  prevent  most  of  the  paralysis  dm1  to  central  causes. 

When  the  accident    occurs  despite  every  effort    put   forth   to  pre- 


LATER    SUBJECTIVE    SYMPTOMS  59 

vent  it,  treatment  must  be  instituted  at  once  and  persisted  in  until 
the  signs  and  symptoms  have  disappeared.  In  many  instances  the 
normal  is  not  obtained  for  several  months  after  the  condition  pre- 
sents itself.  The  actual  measures  for  its  alleviation  consist  prin- 
cipally in  massage,  electrotherapy  and  attention  to  the  general  health 
of  the  individual. 

Pressure  and  tension  are  as  a  matter  of  course  to  be  avoided,  since 
no  patient  who  is  not  reasonably  comfortable  can  be  expected 
make  a  satisfactory  convalescence.  Pressure  may  in  addition  to  be- 
ing a  source  of  discomfort  become  exceedingly  serious,  especially 
when  carried  to  the  point  of  cutting  off  blood  supply.  Where  ban- 
dages are  used  on  the  extremities,  the  toes  and  fingers  should  be  left 
exposed  in  order  that  change  in  color  or  temperature  may  be  readily 
and  quickly  detected.  In  case  they  become  blue  or  cold  every  con- 
striction is  to  be  cut  at  once  no  matter  what  other  factors  come  into 
play,  since  more  than  one  instance  of  gangrene  has  followed  the  post- 
operative swelling  of  an  extremity  which  remained  too  closely  confined. 
Volkmann's  paralysis  is  a  particular  form  of  trouble  which  occurs  in 
the  arm  when  pressure  ischemia  is  maintained  for  too  long  a  period  in 
the  muscles.  The  usefulness  of  many  a  hand  has  been  lost  after  the 
fingers  have  assumed  a  claw-like  posture  resulting  from  permanent 
contraction  of  flexor  muscles  due  to  muscle  substance  being  replaced 
by  scar  tissue  in  consequence  of  the  accident  just  mentioned. 

Pressure  is  particularly  obnoxious  over  bony  prominences,  par- 
ticularly is  this  true  about  the  knee,  ankle,  and  heel.  An  experi- 
enced dresser  is  always  at  pains  to  carefully  and  thickly  pad  these 
prominent  points,  as  well  as  all  those  presented  by  the  bony  pelvis, 
before  applying  a  plaster  cast. 

The  heel  of  a  patient  who  is  to  remain  for  a  long  time  in  the  re- 
cumbent position  should  be  prevented  by  padding  higher  up  on  the 
limb,  from  touching  the  underlying  bed  at  all.  Prolonged  contact 
with  the  bed  is  sure  to  occasion  discomfort,  and  if  not  corrected, 
in  the  course  of  time  is  very  likely  to  lead  to  loss  of  substance.  "We 
have  in  many  instances  been  reminded  of  the  fact  that  more  discom- 
fort and  uneasiness  may  result  from  such  faulty  handling  of  a  pa- 
tient than  from  the  fracture  which  necessitates  his  stay  in  bed. 

The  placing  of  restraining  sheets  over  the  limbs  of  very  lean  pa- 
tients often  results  in  serious  injury  to  the  vessels  or  nerves.  In  this 
connection  the  tourniquet  should  be  mentioned.  In  rare  instances 
injury  to  the  musculospinal  nerve  has  resulted  from  insufficient  pro- 
tection of  the  arm  from  the  constricting  band,  especially  in  cases 
where  this  has  been  placed  too  low  down  and  at  a  point  where  this 
nerve  encircles  the  humerus. 


60  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

Tension  if  extreme  and  too  long  continued  leads  to  unrest  on  the 
part  of  the  patient  and  at  times  to  much  more  serious  consequences. 
Stitches  which  are  too  tightly  tied  inevitably  cut  through  and  not  in- 
frequently lead  to  serious  nutritional  changes  along  the  wound  edges. 

A  high  abdominal  wound  if  closed  with  too  much  tension  prejr 
dices  the  individual's  safety  in  no  uncertain  way.  The  movements 
of  the  lower  chest  wall  are  greatly  interfered  with,  resulting  in  de- 
ficient ventilation  of  the  lung  with  a  consequent  marked  tendency  to 
pneumonia.  I  was  so  unfortunate  as  to  lose  one  of  my  early  post- 
operative hernia  patients  because  I  overlapped  for  too  great  a  dis- 
tance the  edges  of  a  postoperative  hernia  ring  situated  in  the  gall 
bladder  region.  A  second  patient  in  whom  a  similar  error  of  judg- 
ment was  made  seemed  to  be  following  the  same  road  when  his  parox- 
ysm of  coughing  broke  the  stitches  with  the  result  that  he  rapidly 
improved  and  demonstrated  in  no  uncertain  way  the  truth  of  this 
pathologic  reasoning. 

The  amount  of  tension  which  may  be  exerted  upon  an  extremity 
is  almost  unbelievable  provided  merely  that  the  patient  be  very 
gradually  accustomed  to  it.  In  the  old  days  when  we  applied  ten 
or  twelve  pounds  to  an  adhesive  strap  on  the  skin  of  the  lower  leg 
we  considered  that  we  were  doing  all  the  patient  could  expect,  and 
indeed,  met  at  times  with  decided  remonstrance.  I  have,  however, 
in  recent  years  made  extensive  use  of  the  bone  pin  first  suggested 
by  Codavilla  upon  which  a  pull  of  fifty  pounds  lias  been  exerted 
after  gradually  increasing  the  same  for  a  period  of  four  weeks.  I 
can  not  say,  however,  that  I  have  seen  a  patient  thoroughly  comfort- 
able after  the  thirty  pound  limit  was  passed.  A  great  deal  more  can 
be  done  in  this  direction  if  one  commences  before  the  reparative 
process  has  set  in,  whereas  tension  measured  by  only  ;i  few  pounds 
is  apt  to  cause  acute  suffering  if  a  fracture  is  three  or  four  weeks 
old  before  the  treatment  is  begun. 

Full  credit  is  due  0.  F.  McKittrick  for  having  abstracted  all  the 
literature  to  which  reference  is  made  in  this  chapter. 

Bibliography 

iCrandon :      Surgical  After  Treatment.  1909. 

2Posey:     Sajous'  Analytic  Cyclopedia  Practical  Medicine,   1916,  iii,  552. 

sSchepelmann :     Berl.  klin.  Wchnschr.,  No.  21.  1911. 

4Molinari:     Internat.  Obst.  Surg.,  1914,  xviii.    L26. 

sBiidinger:     Arch.  f.  klin.  Cliir.,  xlvii. 

6Deutsch.  med.  Wchnschr.,  1894. 

TGlitsch:     Zentralbl.  f.  Gynak.,  No.  39,  1904. 

sBernhart:     Quoted  by  Halstead.o 

sHalstead:     Wis.  Med  Jour.,  1907-08,  vi,  5-12. 
iQFlateau:     Centralbl.  f.d.  Grenzgeb.  d.  Med.  u.  Chir.,  xl. 
nBuxton:     Anesthetics,  1900,  p.  148. 


CHAPTER  Till 

SLEEPLESSNESS 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Sleeplessness  is  seen  so  frequently  in  postoperative  patients  that 
one  is  more  or  less  inclined  to  regard  it  as  a  normal  occurrence 
rather  than  a  malady  demanding  careful  attention.  As  a  general 
rule  this  subject  is  not  brought  to  the  attention  of  the  attending  sur- 
geon for  several  days  after  the  operative  procedure.  Usually  on  en- 
tering the  hospital  if  the  patient  is  concerned  about  the  operation  or 
is  at  all  nervous  or  restless,  veronal,  gr.  v,  is  given  at  7  p.m.  in  a 
glass  of  hot  milk,  the  night  before  the  operation.  The  drugs  given 
for  the  relief  of  pain  during  the  succeeding  days  are  sufficient  to 
eliminate  any  disturbance  which  would  in  any  way  preclude  sleep. 

After  the  third  postoperative  day,  however,  and  unless  the  patient 
is  in  the  hands  of  a  competent  nurse,  one  often  hears  complaints  that 
the  patient  does  not  sleep  at  night.  It  is  always  to  be  anticipated 
that  such  complications  may  arise  in  any  patient  who  has  been  taken 
from  the  ordinary  pursuit  of  life — howbeit  an  active  one — and  sud- 
denly confined  to  bed.  The  rest,  therefore,  secured  in  the  daytime 
and  the  periods  of  sleep  snatched  off  and  on  during  this  interval 
leaves  the  patient  wide  awake  at  a  time  when,  under  ordinary  cir- 
cumstances, he  would  be  asleep.  A  good  nurse,  expecting  such  an 
outcome,  will  so  entertain  her  patient  that  the  daytime  naps  are  cut 
short  and  he  is  prepared  in  the  most  comfortable  manner  at  bed- 
time. To  do  this  the  bed  is  carefully  arranged  to  the  best  interests 
of  the  patient,  the  feet  kept  warm,  an  alcohol  rub  given,  or  often  the 
nurse  resorts  to  gentle  massage,  particularly  of  the  back.  This  may 
or  may  not  be  followed  by  the  reading  of  some  light  story,  either  by 
the  nurse  or  the  patient  himself.  At  a  regular  time  the  room  is  more 
thoroughly  ventilated,  the  lights  turned  low,  and  sleep  is  demanded 
by  the  nurse  and  invited  by  the  patient.  In  the  handling  of  these 
patients  their  individual  temperaments  and  former  modes  of  life 
are  to  be  minutely  considered. 

It  has  been  said  that  "direct  causes  for  this  malady  do  not  often 
exist  though  they  can  sometimes  be  found,  but  indirect  causes  of 
many  kinds  are  present  in  nearly  every  case. ' '  It  becomes,  therefore, 
a  dire  necessity  to  know  more  about  a  patient's  habits  before  we 

61 


62  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

can  arrive  at  a  definite  conclusion  as  to  the  right  course  to  pursue. 
The  habit  of  taking  several  cups  of  coffee  or  tea  or  other  stimulating 
drinks  may  be  one  fruitful  cause  of  the  condition.  Certainly  such 
is  to  be  thought  of  and  properly  met  in  every  instance.  Occasionally, 
and  particularly  in  old  people  or  in  those  accustomed  to  drink,  it 
is  very  essential  that  they  are  not  deprived  of  their  drink  at  this 
time,  since  a  cup  of  coffee  or  tea  or  a  little  hot  toddy  often  brings 
sleep  when  other  measures  have  failed. 

Some  patients  have  the  habit  of  sleeping  during  the  late  afternoon. 
This  prevents  further  sleep  until  late  at  night  or  in  the  early  morn- 
ing. These  patients,  of  course,  are  not  allowed  to  pursue  this  custom 
when  it  results  in  sleeplessness,  but  are  kept  awake  until  the  regular 
hour  for  sleep. 

Another  cause  of  sleeplessness  in  postoperative  patients  is  lack  of 
food.  This  is  seen  especially  in  very  thin  emaciated  patients.  The 
wait  from  the  b'  p.m.  meal  to  breakfast  is  too  long.  In  these  eases  a 
glass  of  milk,  a  cup  of  cocoa,  or  other  easily  assimilable  food  is  condu- 
cive to  perfect  sleep.  These  patients  are  more  apt  to  be  awake  during 
the  early  morning  hours  and  the  food  given  at  this  time  is  efficacious. 
In  this  connection  the  evening  meal  is  more  often  insufficient  than 
too  heavy  as  a  cause  for  the  patient's  wakefulness.  Food  in  itself 
rarely  causes  the  patient  to  be  awake.  It  is  proverbial  that  animals 
sleep  better  with  a  full  stomach,  and  the  same  very  aptly  applies  to 
human  beings.  Of  course,  the  diet  must  be  so  regulated  that  the 
stomach  already  weakened  by  the  operative  procedure  is  not  over- 
loaded with  indigestible  Pood,  but  the  practice  of  denying  nutritious 
food,  especially  during  the  daytime,  to  these  patients  or  even  at 
night,  because  of  the  fear  that  it  may  cause  disturbance  in  sleep, 
can  not  be  too  heartily  condemned.  <  )n  the  other  hand,  the  recog- 
nition of  the  fact  that  inadequate  food  is  the  cause  of  wakefulness 
can  not  be  too  emphatically  extolled. 

Worry  is  indeed  a  fruitful  cause  for  sleeplessness.  Worry  about 
the  ultimate  outcome  of  the  operation,  strange  as  it  may  seem,  is  not 
so  prominent  in  their  minds  as  the  fact  that  they  do  not  sleep.  Such 
patients  usually  will  have  experienced  this  condition  before  they 
entered  the  hospital  and  on  careful  investigation  one  will  rind  that 
they  fear  some  permanent  injury  as  a  result  of  their  wakefulness. 
Often  they  will  state  to  the  doctor  that  they  sleep  very  little  during 
the  night  and  consequently  feel  that  they  are  losing  hold  on  the  vital 
forces  which  are  so  necessary  for  their  recovery  from  the  operation 
or  even  future  health.  They  become  very  solicitous  as  to  the  nature  of 
the  malady  and  implore  their  physician  for  relief.     They  may  not 


SLEEPLESSNESS  63 

liave  really  lost  very  much  sleep  but  complain  of  wakening  so  often 
during  the  night  and  never  going  back  to  sleep.  It  will  be  noticed, 
however,  that  they  do  finally  go  to  sleep,  and  the  length  of  time  they 
were  awake  is  only  magnified  and  apt  to  have  been  thought  much 
longer  than  it  really  was.  That  the  statements  of  these  patients  can 
not  always  be  taken  too  seriously  is  borne  out  by  the  statement  of 
Walsh,1  who  says  that,  "We  have  no  idea  as  to  the  length  of  our 
sleeping  periods,  and  if  we  awaken  a  dozen  times  during  the  night 
we  are  likely  to  think  that  we  have  been  wakeful  most  of  the  night, 
though  all  the  wakeful  periods  may  be  embraced  within  an  hour, 
and  the  rest  have  been  spent  in  sleep." 

In  these  patients  I  try  to  verify  their  statements  by  having  them 
watched  by  the  nurse  whose  findings  are  always  more  to  be  relied 
upon  than  the  neurotic  patient's  ideas. 

Occasionally  one  finds  his  patient  concerned  about  sleep  during 
the  coming  nights  he  is  to  spend  in  the  hospital.  He  will  start  wor- 
rying and  "just  wondering"  if  he  is  going  to  sleep  when  that  time 
comes.  If  one  makes  rounds  along  late  in  the  afternoon  he  is  more 
apt  to  see  these  patients  at  the  time  when  they  are  in  their  zenith  of 
anxiety  concerning  the  sleep  they  will  not  get  with  the  coming  of  the 
night.  This  certainly  is  ridiculous  and  is  trying  for  those  in  charge 
of  a  sensible  patient  who  is  addicted  to  this  miserable  habit,  never- 
theless it  is  one  to  be  reckoned  with  and  combated  as  best  the  nurse 
knows  how  coupled  with  whatever  therapy  the  doctor  can  advise. 

This  class  of  patients  really  do  lose  sleep,  not  because  of  any  real 
physical  difficulty,  but  because  of  the  fact  that  they  worry  over  the 
insomnia  itself  which  is  sufficient  to  bring  whatever  dire  results  such 
a  condition  entails. 

The  worry  of  the  effect  which  the  patient  imagines  insomnia  will 
produce  on  his  mind  and  body,  is  another  factor  which  materially 
adds  to  the  seriousness  of  the  situation.  Naturally  the  general  con- 
dition becomes  run  down,  the  convalescence  prolonged,  and  the  pa- 
tient considers  that  his  sleeplessness  is  to  blame  for  the  condition, 
when  as  a  matter  of  fact,  the  fear  alone  is  the  cause  of  his  unhappy 
state.  As  soon  as  the  thought  of  impending  mental  affection  is  eradi- 
cated from  the  patient's  mind,  the  wakefulness  will  become  easy  to 
control.  Insomnia,  to  be  true,  has  occurred  during  the  course  of  this 
malady.  Personally  I  have  never  seen  it  follow  postoperative  insom- 
nia. Walsh  states  that  he  has  seen  it  develop  as  one  of  its  symp- 
toms, but  not  even  then  until  other  marked  signs  of  mental  affection 
were  present.  He  further  states  that  "Wakefulness  is  really  a  passing 
symptom  of  functional  nervous  condition  that  never  leaves  serious 


64  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

effects,"  an  observation  in  which  I  can  entirely  acquiesce  when  the 
ordinary  postoperative  patients  are  alone  considered.  Such  infor- 
mation often  helps  the  patient  to  calm  himself,  and  is  one  of  the  ar- 
guments employed  in  assisting  him  to  regain  a  stable  equilibrium 
when  other  measures  as  instituted  below  are  utilized  to  complete  the 
successful  treatment  of  the  case. 

One  of  the  most  common  causes  of  obstinate  insomnia  in  cases  not 
operated  is  errors  of  refraction  according  to  Pronger2  who  states 
that  it  is  not  the  gross  errors  which  so  often  lead  to  the  condition, 
but  rather  the  slight  ones,  such  as  do  not  lead  to  such  visual  defect 
as  to  demand  the  wearing  of  glasses  for  their  correction.  The  con- 
tinual effort  in  the  use  of  the  eyes  leads  to  a  cumulative  nervous 
strain  which  results  in  sleeplessness.  Unfortunately  these  patients 
fall  into  the  hands  of  the  surgeon  for  various  operations,  and  unless 
such  a  cause  is  considered  possible,  the  patient  may  suffer  unneces- 
sarily even  to  the  point  of  a  general  breakdown,  and  Pronger  states 
that  even  suicide  has  been  perpetrated  by  patients  suffering  from 
insomnia  due  to  this  cause  alone.  I  have  never  had  such  an  accident 
occur  though  on  one  or  two  occasions  patients  have  intimated  that 
this  might  result  if  sleep  did  not  become  more  satisfactory.  Clarke'' 
in  supporting  Pronger  states  that  the  unconscious  correction  of 
small  refractive  errors  always  leads  to  waste  of  the  nerve  energy 
sooner  in  those  whose  nervous  organization  is  more  delicate  than  in 
the  robust,  in  whom  it  may  never  present  itself.  This  statement, 
however,  should  not  prevent  one  from  examining  the  eyes  in  the 
latter  class  of  patients  when  other  causes  have  been  exhausted. 

Gubb4  in  discussing  the  same  subject  calls  attention  to  the  fact 
that,  not  only  does  this  trifling  disturbance  produce  insomnia,  but 
also  others  even  less  so  will  cause  the  same  distressing  symptoms. 
A  loaded  rectum,  especially  where  there  is  a  tendency  to  flatulence, 
tends  to  excite  peristalsis  and  result  in  wakefulness.  Williams5  notes 
that  toxemia  resulting  from  a  severe  colitis  may  also  produce  this 
same  condition.  In  fact  the  sleeplessness  associated  with  bowel  dis- 
turbance due  to  operative  procedures  is  well  known,  probably  as  a 
result  of  autointoxication  as  well  as  the  increased  peristalsis  neces- 
sarily produced. 

The  after  observance  that  the  height  of  the  head  can  not  be  ignored 
if  sleeplessness  is  to  be  avoided  in  some  patients  is  also  brought  out 
by  Gubb.  The  temperature  of  the  room  is  important.  A  cool  or 
rather  cold  room  is  certainly  desirable  for  a  normal  sleep,  and  the 
free  circulation  of  air  is  by  all  means  to  be  obtained.  Cold  air.  how- 
ever, coming  in  contact  with  exposed  surfaces  of  the  patient's  body 


SLEEPLESSNESS  65 

is  not  conducive  to  perfect  sleep  or  future  health  of  the  patient,  and 
measures  taken  to  prevent  this  happening  are  always  observed  in 
postoperative  cases. 

Further  causes  for  sleeplessness  may  be  found  and  corrected  when 
some  of  the  theories  of  sleep  itself  are  brought  to  mind  and  briefly 
considered.  Savage6  states  that  normal  sleep  depends  upon  a  healthy 
blood  supply  to  normal  nerve  cells,  particularly  these  of  the  frontal 
lobes.  He  considers  that  blood  supply  to  the  brain  lias  most  to  do 
with  sleep  and  recalls  that  sudden  loss  of  this  body  fluid  will  produce 
insensibility,  or  pressure  on  both  common  carotids  will  cause  the  same 
phenomena.  Howell7  found  that  the  brain  became  anemic  and  the 
blood  pressure  dropped  during  sleep.  The  skin  in  the  meantime  con- 
tained an  increased  amount  of  blood,  which  shows  that  the  vaso- 
motor system  is  in  some  way  involved.  Hill*  considers  the  vasomotor 
center  as  the  "hub  around  which  turns  the  wheel  of  a  man's  active 
mental  life."  Savage  suggests  that  there  may  be  a  venous  conges- 
tion which  produces  a  malnutrition  of  the  nerve  cells  which  is  as 
capable  of  producing  sleep  as  anemia.  Miller9  would  consider  ""  cere- 
bral stasis"'  as  a  more  likely  cause  of  sleep  than  cerebral  anemia  the 
result  of  the  stasis  bringing  about  practically  the  same  cell  changes 
as  the  former  condition.  Stoddart10  supports  the  theory  that  there 
is  a  carbon  dioxide  poisoning  of  the  nervous  system  during  sleep. 
In  discussing  this  theory  he  recalls  the  habits  of  animals  in  their 
mode  of  producing  sleep.  In  every  instance  the  normal  supply  of 
oxygen  is  shut  off  either  by  burying  their  noses  in  hairy  portions 
of  their  body  and  at  the  same  time  twisting  the  body  so  as  to  get 
the  minimum  amount  of  oxygen  into  the  lungs.  Birds  tuck  their 
heads  under  their  wings. 

Man  becomes  sleepy  in  stuffy  rooms,  and  how  often  one  finds  pa- 
tients sleeping  with  the  head  completely  covered.  He  directs  atten- 
tion to  the  fact  that  patients  suffering  from  diseases  in  which  there 
is  deficient  oxidation  such  as  in  nasal  obstruction,  heart  disease,  ane- 
mia, etc..  sleep  soundly,  while  those  suffering  from  fever  and  other 
conditions  in  which  chemical  changes  and  oxidation  take  place  too 
readily  suffer  from  sleeplessness.  Stoddart  has  shown  that  by  di- 
recting a  noiseless  stream  of  oxygen  to  the  face  of  a  sleeping  patient 
by  means  of  a  rubber  tube  attached  to  a  tank  of  oxygen,  he  can  cause 
the  patient  to  awaken  in  every  instance  within  forty  respirations, 
even  though  the  stream  of  oxygen  is  not  allowed  to  play  directly  on 
the  face. 

Bramwell11  staunchly  supports  Stoddart  in  his  resuscitation  of 
the  carbon  dioxide  theory  of  sleep  and  in  the  discussion  on  this  sub- 


66  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

ject  lie  states  that  this  phenomena  is  much  too  complicated  a  process 
to  present  a  single  factor  for  its  origin.  He  considers  almost  all  the 
theories  advanced  "are  equally  important  and  must  exist  together 
and  at  the  same  moment  in  order  to  produce  healthy  or  natural 
sleep."  If  there  is  one  theory  more  important  than  another,  he 
would  place,  perhaps,  "psychic  calm,"  for  "if  this  is  absent  two 
other  conditions  essential  to  sleep  must  also  be  absent;  namely,  a 
lowered  or  a  certain  required  blood  pressure  and  cerebral  anemia  or 
stasis."  Bramwell  suggests  that  "patients  whose  ocular  muscles  are 
intact  and  therefore  without  danger  of  strain,  should  turn  the  eyeballs 
upwards,  with  the  lids  closed  as  in  sleep.  This  will  promote  a  feeling 
of  drowsiness"  while,  as  so  often  experienced  by  all  of  us,  "to  turn 
them  downwards  causes  an  opposite  effect,  with  tremor  of  the  up- 
per lids  and  a  tendency  to  squeeze  the  upper  and  lower  lids  together." 

Treatment  further  than  has  been  suggested  above  may  become 
necessary  to  relieve  the  minds  of  these  unhappy  and  often  appre- 
hensive patients.  The  drug  treatment  is  to  be  avoided  if  this  is  pos- 
sible. Probably  the  first  measure  to  be  attempted  is  to  find  the  cause 
of  the  condition.  This  is  as  important  in  the  convalescent  surgical 
patient  as  in  those  sufferers  from  medical  causes  alone.  Any  per- 
nicious habit  is  so  far  as  possible,  corrected.  Hygienic  measures  as 
suggested  above  are  rigidly  enforced  and  the  patient  when  fixed  up 
for  the  night  lies  perfectly  quiet  in  anticipation  of  sleep.  He  at- 
tempts to  leave  his  mind  a  blank  and  no  disturbing  thought  is  al- 
lowed to  remain  a  single  moment. 

Turning  the  eyeballs  upward  as  suggested  by  .Mil lee  or  slighl 
pressure  on  them  by  the  nurse  may  in  some  instances  be  conducive 
to  hastening  sleep  in  the  very  nervous  individual  whose  mind  nat- 
urally is  overactive.  Hypnotism'-  is  suitable  in  some  cases,  and 
when  intelligently  administered  has  been  extremely  valuable  in  some 
instances.  Suggestion  is  another  factor  which  must  not  be  underes- 
timated in  patients  whose  confidence  and  perfect  trust  has  been  se- 
cured by  the  doctor  or  the  nurse. 

The  gastrointestinal  tract  should  never  in  any  instance  be  neg- 
lected. Autointoxication  from  excretory  products  is  carefully 
guarded  against  by  keeping  the  bowels  open,  giving  a  carbohydrate 
diet  if  an  excessive  putrefactive  process  is  suspected,  and  other  elim- 
inative  measures  actively  and  consistently  carried  out. 

In  this  connection  I  would  not  fail  to  note  the  patient's  hunger 
and  at  once  supply  food.  Usually  liquid  foods,  hot  and  in  some  cases 
a  placebo,  such  as  a  little  nutmeg  sprinkled  over  the  fluid  will  give 
an  additional  assurance  of  the  patient's  rest  after  the  food  is  given. 


SLEEPLESSNESS  67 

If;  however,  some  solid  food  is  demanded,  this,  too,  is  not  denied  so 
long  as  actual  indigestion  does  not  cause  more  disturbance. 

The  eyes  should  not  be  overlooked  in  any  case  where  there  is  any 
suspicion  of  trouble.  The  assistance  of  an  oculist  will  solve  many 
hard  problems  in  dealing  with  some  of  the  most  intractable  cases. 

Hydrotherapy  is  often  followed  by  good  results.  A  warm  bath  be- 
fore retiring  or  a  sponge  by  the  nurse,  followed  by  an  alcohol  rub, 
gentle  massage  or  both,  will  be  rewarded  by  good  results.  The  value 
of  the  hot  foot  bath  resorted  to  by  many  patients  is  well  known. 
Some  even  employ  the  mustard  bath  to  the  point  of  getting  a  general 
redness,  a  practice  which  I  have  never  been  compelled  to  utilize  in 
the  postoperative  patient. 

The  drug  treatment  is  employed  as  the  final  resort.  If  there  is 
pain,  this,  of  course,  is  at  once  relieved  without  delay.  I  have  found 
10  grains  of  aspirin  combined  with  1  grain  of  codeine  indeed  very 
efficacious.  The  codeine  is  alone  repeated  if  it  becomes  necessary. 
Opium  suppository  (1  grain)  will  often  give  relief  in  abdominal  or 
pelvic  cases,  and  at  the  same  time  the  patient  is  not  aware  of  any 
medication  given.  Where  there  is  painful  peristalsis,  paregoric,  1 
dram,  given  each  hour  will  relieve,  and  permit  sleep.  Chloral  hy- 
drate, 30  grains,  per  rectum  in  a  little  oil  may  be  employed  in  those 
patients  not  suffering  from  pain.  Paraldehyde,  60  grains,  may  also 
be  given,  either  by  mouth  or  rectum.  Veronal  or  sulphonal,  5  grains 
each,  given  in  hot  liquids  is  frequently  employed. 

The  bromides,  given  during  the  day  and  at  bedtime,  have  been 
used  for  sleeplessness  since  medicine  first  came  into  existence.  I 
often  follow  this  old-time  custom,  and  in  many  instances  meet  with 
success.  The  bromides,  however,  are  slow  in  their  action  and  can 
not  be  relied  upon  in  all  cases  of  malady  appearing  in  patients  who 
have  gone  through  a  major  operation. 

Bibliography 

iWalsh:     Internat.  Clin.,  1914,  ii,  series  24,  p.   121. 

sPronger:     Lancet,  London,  1914,  ii,  1357,  also  New  York  Med.  Join-     1915,  ci, 
37.  Ohs. 

3Clarke:     Lancet,  London,  1915,  i,  98. 

tGrubb :     Ibid. 

sWilliams:     Virginia  Med.  Semi-Month.,  1913-14,  xix,  339. 

eSavage:     Brit.  Med.  Jour.,  1913,  ii,  1206. 

^Howell:     Textbook  On  Physiology. 

sHill:     Quoted  by  Savage. 

aMiller:     Bait.  Med.  Jour.,  1913,  ii,  1212. 
loStoddart:     Ibid.,  1208. 

nBramwell:     Brit.  Med.  Jour.,  1913,  ii,  15  to  63. 
i2Long:     Brit.  Med.  Jour.,  1913,  ii,  1209. 
The  following  was  also  consulted: 
Morris:     Analytic  Cyclopedia  Practical  Medicine,  1916,  i,  10. 


CHAPTER  IX 

HICCOUGH 

By  0.  F.  McKittriek,  St.  Louis,  Mo. 

Hiccough  (singultus,  hiccup)  occurs  frequently  after  abdominal 
operations.  As  a  rule,  it  is  an  unimportant  malady,  one  characterized 
by  mild  and  transitory  attacks,  which  cease  automatically  or  else 
is  amenable  to  the  simplest  treatment.  However,  it  may  be  the  fore- 
runner of  the  gravest  complication,  whether  associated  with,  or  in 
the  absence  of,  some  form  of  chronic  disease,  the  affection,  either  in 
its  acute  or  chronic  form,  becomes  extremely  distressing  if  it  per- 
sists over  long  periods  of  time  and  occasionally  this  happens  despite 
every  effort  made  to  control  it.  The  exhaustion  which  is  necessarily 
entailed  may  lead  to  the  fatal  termination  of  an  otherwise  normal 
convalescence. 

According  to  most  observers,  hiccough  is  produced  by  sudden,  in- 
voluntary clonic  contractions  of  the  diaphragm,  with  which  the  nor- 
mal action  of  the  vocal  chords  fail  to  synchronize.  The  unexpected 
descent  of  the  diaphragm  further  increases  the  negative  pressure  in 
the  chest  into  the  viscera  of  which  the  outside  air  rushes  but  is 
partly  checked  by  the  nearly  closed  glottis.  The  air  which  enters 
causes  sudden  vibration  of  the  vocal  chords,  the  characteristic  coarse 
sound  being  thereupon  emitted.  It  is  considered  by  some  that  there 
is  spasmodic  contraction  of  the  abductors  of  the  cords  which  com- 
pletely stops  the  entry  of  the  air,  hid  ('air1  thinks  this  improbable. 

There  is  a  double  nervous  mechanism  which  is  concerned  in  hic- 
cough. According  to  Sajous,2  the  vagospinal  nerves  bring  aboui 
closure  of  the  glottis  and  contraction  of  the  stomach  with  accom- 
panying relaxation  of  the  pyloric  sphincter.  The  phrenic  nerve  con- 
trols the  diaphragm  and  a  (enter  which  coordinates  these  movements 
is  supposed  to  exist  in  the  medulla,  its  action  being  stimulated  by  im- 
pulses from  numerous  efferent  nerves  which  are  indirectly  connected 
with  it.  Irritation  from  the  absorption  of  toxins  or  from  any  other 
source  may  bring  about  this  condition  by  stimulation  of  the  phrenic 
nerves  at  their  origin  (in  the  fourth  cervical  nerves)  anywhere  along 
their  course  to  the  diaphragm  or  in  their  terminal  libers  in  the  under 
surface  of  this  muscle. 

Stimulation  of  the  third  or  fifth  cervical  nerves,  will  also  theo- 
retically   bring    about    such    a    result.      It    therefore    follows    that    re- 

68 


HICCOUGH  69 

flex  stimulation  may  occur  through  the  branches  of  the  vagus  nerve, 
particularly  its  gastric  terminations,  or  irritation  in  any  organ  or 
tissue  supplied  by  this  nerve,  may  cause  like  phenomena.  Stimula- 
tion of  other  visceral  nerves  as  those  to  the  uterus,  bladder,  kidneys, 
etc.,  or  involvement  of  the  peripheral  sensory  nerves  may  through 
reflex  action  bring  about  hiccough.  Stimulation  of  the  center  con- 
trolling these  phenomena  may  also  produce  this  condition. 

The  most  frequent  cause  is  reflex  stimulation  of  the  phrenic 
nerves  through  the  gastric  branches  of  the  vagus.  Hence  very  hot 
or  very  cold  fluids,  an  excess  of  condiments  in  the  food  whether  fluid 
or  solid,  overeating,  or  the  retention  of  undigested  food  particles  in 
the  stomach,  distention  of  this  organ  or  any  irritative  factor  in  the 
intestines,  such  as  feces  at  times,  an  enteritis  due  to  parasitic  infec- 
tions, etc.,  may  be  fruitful  inciting  causes.  Functional  or  organic  dis- 
eases of  these  viscera,  associated  with  an  overlying  irritated  perito- 
neum, particularly  that  on  the  diaphragmatic  surface  are  common 
causes. 

Bassler3  reported  two  cases  of  persistent  hiccough  due  to  a  hyperes- 
thesia of  the  stomach.  The  condition  which  he  named  "singultus 
gastritis  nervcsus"  was  one  associated  with  loss  of  weight  in  the  pa- 
tient caused  by  the  constant  irritation  of  the  food,  etc.  The  condi- 
tion is  very  rarely  met,  but  it  may  be  a  source  of  some  obstinate 
case  and  should  be  borne  in  mind. 

Persistent  hiccough  is  usually  of  grave  import  in  peritonitis,  par- 
ticularly if  associated  with  some  abdominal  malady.  In  a  case  ob- 
served hiccough  persisted  two  weeks  just  before  death  of  the  patient 
after  an  exploratory  laparotomy  in  which  was  found  an  inoperable 
carcinoma  of  the  stomach.  Although  the  peritoneum  was  free  at 
the  time  of  the  laparotomy,  at  autopsy,  three  weeks  later,  there  was 
quite  extensive  involvement.  Another  case  in  which  persistent  hic- 
cough occurred  was  seen  in  a  patient  suffering  from  inoperable 
carcinoma  of  the  bladder.  The  hiccough  developed  one  week  after 
an  exploratory  operation  and  persisted  until  the  patient's  demise 
two  weeks  later. 

It  usually  comes  late  in  a  disease  and  at  a  time  when  the  abdomen 
is  distended.  Particularly  is  this  true  in  intestinal  obstruction,  ul- 
cerative conditions  of  the  intestines,  pancreatitis,  diseases  of  the 
uterus,  prostate,  or  bladder.  Marion4  believes  this  symptom  occurring 
after  operations  on  the  urinary  tract  is  in  the  great  majority  of  cases, 
a  uremic  manifestation ;  hence  in  patients  suffering  from  chronic 
kidney  diseases,  this  symptom  is  particularly  ominous.  The  condition 
may  intermit  for  varying  lengths  of  time,  and  recurs  without  apparent 


70  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

reason ;  after  several  days  of  suffering  during  which  the  patient  loses 
considerable  weight,  he  becomes  very  much  enfeebled.  It,  however, 
not  infrequently  causes  death  in  such  cases  without  the  symptoms 
ever  becoming  abated.  The  comparatively  frequent  occurrences  of 
hiccough  in  fatal  cases  where  there  are  extravasations  of  urine  after 
an  operation  for  the  relief  of  stricture,  is,  no  doubt,  due  to  some 
associated  kidney  lesion. 

Diseases  of  the  thoracic  viscera  may  cause  this  symptom.  Affec- 
tions of  the  pericardium  or  diaphragmatic  pleura  especially  may 
result  in  distressing  hiccough.  Contamination  of  the  blood  by  toxic 
or  infectious  materials  such  as  those  produced  in  pneumonia  or  gen- 
eral septic  infection  may  produce  this  phenomenon.  In  such  con- 
ditions it  seems  probable  that  tbe  nerve  centers  are  involved  as  well 
as  the  diaphragm  or  the  nerves  themselves.  In  operative  patients 
who  are  suffering  at  the  same  time  from  gout  or  diabetes,  the  blood, 
especially,  plays  an  important  role. 

Local  irritations  from  abdominal  or  pleural  pus  collections  not  un- 
commonly cause  irritation  of  the  nerves  which  supply  the  diaphragm 
as  do  tumors  located  in  the  mediastinum,  in  the  neck,  or  in  the  lungs 
by  pressure  on  the  phrenic  nerve.  Green3  reported  a  case  of  hic- 
cough which  persisted  for  six  months  and  ended  in  death  of  the  pa- 
tient. At  autopsy  ;i  small  malignant  growth  was  found  at  the  hilus 
of  the  lung  which  evidently  had  caused  the  irritation  of  the  phrenic 
nerve. 

Hiccough  may  be  due  to  central  irritation  or  to  reflex  stimuli  in 
neurotic  patients.  It  may  occur  in  hysterical  patients  or  those  suf- 
fering from  epilepsy.  Cerebral  tumors6  occasionally  bring  about  such 
a  condition  or  it  may  follow  shock,  some  emotional  disturbance,  or 
organic  functional  disease  of  the  nervous  system.  In  a  case  of  per- 
sistent intermittent  hiccough  seen,  every  known  measure  was  em- 
ployed  to  stup  the  paroxysms.  The  patient's  blood  was  examined  for 
syphilis  and  showed  a  negative  Wassermann.  Certain  siyns  sug- 
gested a  tabes  dorsalis.  In  spite  of  the  negative  blood  findings,  anti- 
syphilitic  treatment  was  instituted  with  prompt  amelioration  of  the 
symptoms  which  never  returned. 

Peripheral  irritation  in  neurotic  patients  may  result  in  tin1  ap- 
pearance of  these  symptoms.  I  have  seen  hiccough  follow  exposure 
to  cold,  especially  to  sudden  chilling  of  the  body,  after  bathing  in 
cold  water.  0*Reilly7  reported  a  case  which  was  being  treated  for 
hepatic  cirrhosis;  hiccough  persisted  despite  the  usual  routine  treat- 
ment. Finally  the  ears  were  examined  and  impacted  wax  was  found 
and  removed.    The  hiccough  ceased  without  further  treatment. 


HICCOUGH  71 

Hiccough  occurs  in  too  many  conditions  to  attempt  to  name  them. 
As  King  has  said,  it  may  occur  in  almost  any  acute  or  chronic  ex- 
hausting disease.  The  condition  may  be  of  little  importance  in  the 
everyday  routine  of  life,  but  after  operation  it  should  be  especially 
enjoined  that  in  every  case,  the  cause  of  the  condition  should  be  de- 
termined if  possible,  and  this  corrected  before  the  patient  passes  be- 
yond relief,  because  of  exhaustion  or  on  account  of  the  disease  which 
is  producing  the  symptoms. 

The  remedies  employed  for  the  treatment  of  this  malady  are 
legion.  This  is  the  best  proof  we  have  that  no  one  remedy  is 
effectual  in  every  case.  However,  the  measures  which  we  will  men- 
tion are  those  known  by  us  to  be  worth  trying  under  such  circum- 
stances. I  have  never  failed  to  stop  this  symptom  except  on  the 
two  occasions  mentioned  above,  and  these  patients  were  dying  from 
inoperable  cancer. 

In  most  cases,  the  simpler  remedies  will  usually  suffice,  among 
them  may  be  mentioned  the  drinking  of  one-half  glass  of  water  in 
which  a  teaspoonful  of  sodium  bicarbonate  has  been  placed,  swallow- 
ing of  ice,  sucking  a  lemon,  taking  a  little  vinegar  or  common  table 
salt.  Probably  one  of  the  oldest  and  most  efficient  of  the  common 
remedies  is  the  holding  of  the  breath  while  large  swallows  of  water 
are  taken.  King  suggested  that  the  patient  at  the  same  time  stop 
the  ears  with  his  fingers  while  his  nose  is  held  tightly  closed.  Air  is 
thus  prevented  from  entering  the  pharynx  except  through  the  mouth. 
If  two  or  three  trials  fail  to  stop  the  symptoms,  the  tongue  should 
be  thrust  out  synchronous  with  each  respiration,  which  should  now  be 
increased  to  30  to  50  per  minute.  Each  respiration  should  be  deep. 
This  however,  exhausts  the  patient  and  should  not  be  kept  up  very 
long  at  a  time.  Massage  along  the  course  of  the  phrenic  nerves  in 
the  neck  or  counterirritation  with  mustard  leaves  here  as  well  as 
over  the  epigastrium  may  prove  an  efficacious  treatment.8  If  the 
symptoms  continue,  the  alimentary  tract  should  be  freed  of  all  ma- 
terial which  can  be  the  causative  factors.  If  the  nature  of  the 
operation  permits,  free  catharsis  may  be  instituted  by  giving  pur- 
gatives per  mouth,  otherwise,  enemas  will  suffice.  The  stomach 
should  be  emptied.  A  simple  emetic  such  as  a  teaspoonful  of  mus- 
tard in  a  cup  of  warm  water  may  be  tried  at  first.  Apomorphine, 
Y10  grain  subcutaneously  is  particularly  suitable  in  that  not  only 
is  the  stomach  emptied,  but  the  act  of  vomiting  causes  the  diaphragm, 
to  contract  violently  and  this  alone  may  stop  the  clonic  spasms. 
The  tube  may  be  used  also  for  clearing  the  stomach,  and  in  pa- 
tients unused  to  it,  this  is  especially  indicated.     With  the  gastroin- 


72  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

testinal  tract  cleared  out,  other  remedies  can  now  be  tried.  Since 
so  many  different  drugs  have  now  and  then  acted  well  in  different 
patients,  it  is  probably  advisable  to  continue  the  use  of  other  medi- 
cinal measures.  Inhalation  of  amyl  nitrate  or  injections  of  cocaine, 
V-io  to  %o  grain  hypodermically,  may  be  tried. 

By  all  means  force  the  intake  of  large  amounts  of  water,  in  which 
sodium  bicarbonate  is  freely  given.  Other  measures  such  as  me- 
chanical interference  may  be  employed.  Forceful  manual  compres- 
sion of  the  costal  margins  of  the  lower  ribs  and  the  epigastrium  at 
intervals  of  three  or  four  minutes  is  good,  or  a  tight  adhesive  binder 
may  be  placed  around  the  lower  portion  of  the  thorax.  Jodicke9  de- 
scribes a  good  method  for  obstructing  the  diaphragmatic  movements. 
He  forces  the  intestines  up  against  this  muscle  by  flexing  the  legs 
upon  the  thighs  and  has  them  flexed  on  the  abdomen  and  pressed  as 
firmly  as  possible  against  this  part  of  the  body.  He  reported  a 
serious  case  in  which  this  procedure  was  successfully  employed.  The 
hiccough  stopped  in  ten  minutes.  The  condition  is  relieved  in  many 
instances  by  the  patient  placing  his  arms  above  his  head  and  then 
pulling  his  weight  upward  in  the  bed  by  holding  to  the  head  railing. 

If  in  spite  of  all  the  measures  suggested,  the  symptoms  persist, 
the  kidneys  may  be  at  fault  and  measures  should  be  undertaken  as 
described  under  the  treatment  of  uremia.  Should  the  symptoms  still 
persist,  then  morphine  must  be  resorted  to.  It  should  be  given  hy- 
podermically until  the  full  physiologic  effects  are  seen.  In  one  case 
that  I  have  treated  the  respiration  was  cut  down  to  four  per  minute, 
while  in  another  it  was  diminished  to  only  three  per  minute.  One 
patient  was  cured  and  the  other  temporarily  relieved.  Caffrey10 
failed  to  stop  the  symptoms  in  a  severe  ease  by  using  this  method, 
then  he  injected  ',.-,,,  atropine  sulphate  subcutaneously  and  the  symp- 
toms at  once  cleared,  never  to  return.  The  hiccough  had  persisted 
four  years,  and  in  this  time  every  known  remedy  had  been  tried. 

Chloral  hydrate  and  the  bromide-;  have  been  used  repeatedly  with 
varying  degrees  of  success.  Recently,  Segal  used  epinephrin,  10 
drops  of  a  1:1000  solution,  which  stopped  a  hiccough  which  had 
lasted  eleven  days,  even  in  spite  of  chloroform  anesthesia.  Lately, 
Mead11  reported  a  case  which  was  cured  by  menthol  after  none  of  the 
usual  methods  had  brought  relief,  lie  uses  10  drops  of  a  saturated 
solution  of  menthol  in  spiritus  vini  recti  and  this  is  repeated  every 
hour  if  necessary. 

In  babies,  hiccough  may  be  stopped  by  giving  them  plain  water. 
Grape  sugar  or  granulated  sugar  placed  in  the  mouth  often  stops 
the  malady.     In  older  children,  the  same  measures  are  used  as  those 


HICCOUGH  73 

employed  for  adults,  except  perhaps  the  medication.  The  mechani- 
cal measures  should  be  persisted  in  for  longer  periods  of  time  than 
with  adults.     Provoking  sneezing  may  be  efficacious. 

In  hysterical  or  neurotic  patients,  the  treatment  as  suggested  for 
older  children  should  first  be  tried.  Autosuggestion  or  hypnotism 
is  indicated.  Valerian  is  especially  efficacious.  Ether  narcosis  may 
be  employed  as  a  last  resort  in  the  usual  persistent  case  of  hiccough 
which  is  threatening  life,  but  in  these  hysterical  patients,  it  should 
be  employed  early  in  the  condition.  The  hiccough  rarely  returns 
after  the  first  narcosis. 

The  esophageal  sound  has  been  passed  successfully  in  a  few  in- 
stances, one  such  was  reported  by  New12  at  the  Mayo  Clinic,  in  over- 
coming a  hysterical  hiccough.  The  patient  had  been  operated  sev- 
eral times,  for  various  conditions  among  which  were  appendicitis 
and  stone  in  the  kidney.  After  each  operation,  the  patient  had  hic- 
cough which  lasted  from  one  to  twelve  hours.  After  the  last  oper- 
ation, hiccough  appeared  at  short  intervals  for  four  months,  after 
which  date  it  persisted  day  and  night  for  five  months  longer.  The 
rate  of  the  hiccough  varied  from  20  to  72  per  minute.  During  this 
time  many  measures  were  tried  to  secure  relief.  C.  H.  Mayo  ad- 
vised intubation  since  he  believed  the  nervous  condition  alone  pro- 
duced the  symptoms.  Following  intubation  with  the  largest  size  of 
O'Dwyer  tube  the  hiccough  stopped  at  once.  Three  hours  later,  the 
tube  was  coughed  up  and  the  hiccough  started  again.  The  tube  was 
again  introduced  and  remained  eight  hours  in  place,  after  which 
time  it  was  coughed  up  but  the  hiccough  did  not  return.  The  pa- 
tient was  permanently  cured. 

Intubation  therefore  is  placed  on  the  list  of  the  many  remedies  for 
this  condition,  but  no  treatment  should  be  left  untried  in  the  hope 
of  finding  something  which  will  relieve  the  patient  of  a  symptom 
which  more  than  once  has  demanded  death  for  its  toll. 

Bibliography 

iCarr:      The  Practitioner,  1911,  xxxvii,  519. 

2Sajous:     Analytic  Cyclopedia  Practical  Medicine,   1916,   v,   530. 

sBassler:      New  York' Med.  Jour.,  1910,  xcii,  311. 

4Marion:      Jour.  d'Urol,  1913,  iii,  580. 

sGreen:     Med.  Klin.,  July,  1911. 

sKing:     New  York  Med.  Jour.,  1911,  xciii,  826. 

^O'Eeillv:     Canadian  Lancet,  Feb.,  1914. 

sWoodwark:     Pract.  Encycl.  Med.  Treat.,  1916,  p.   316. 

ajodicke:      Med.  Klin.,  May,   1911. 
iQCaffrey:     Jour.  Am.  Med.  Assn.,  1913,  Ix,  1S79. 
nMead:      Med.   Bee,  New  York,   January,   1914. 
i2New:   St.  Paul  Med.  Jour.,  1913,  xv,  466. 


CHAPTER  X 

HEADACHE 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Headache  is  one  of  the  most  common  symptoms  with  which  the 
medical  profession  lias  to  deal.  It  is  natural,  therefore,  that  it 
should  present  itself  frequently  in  the  postoperative  patient,  and  for 
this  reason  we  are  forced  into  the  discussion  of  a  subject  upon  which 
volumes  already  have  been  written.  However,  a  certain  amount  of 
familiarity  with  its  various  forms  is  essential,  in  order  to  intelli- 
gently carry  out  adequate  treatment  when  the  occasion  arises.  The 
disturbance  maybe  very  mild  and  transient  in  nature,  not  indicating 
any  especially  important  upset  in  the  patient's  condition,  or  it  may 
become  quite  severe,  being  the  forerunner  of  some  important  com- 
plication.    It  often  accompanies  some  serious  constitutional  disease. 

This  symptom  arises  as  a  result  of  an  almost  unlimited  number 
of  disorders,  and  the  mechanism  of  its  production  is  still  one  of  the 
unsolved  mysteries  of  medicine.  It  has  been  thought  to  be  due  to 
irritation  of  the  terminal  sensory  branches  of  the  fifth  nerve  or  the 
vagus  branch  supplying  the  meninges.  The  pain  most  commonly 
complained  of  is  a  dull  ache  or  throbbing  in  the  head,  but  frequently 
it  is  acute,  sharp,  shooting,  boring  or  stabbing.  It  may  continue  for 
a  number  of  hours  or  days,  but  is  more  likely  to  be  transient  or 
paroxysmal  in  occurrence. 

The  location  of  the  pain  in  the  bead  is  of  little  importance,  accord- 
ing to  Cabot.1  Ocular  headache  usually  begins  or  centers  around  the 
region  of  the  eyes,  whereas  that  due  to  inflammation  of  the  frontal 
sinus,  antrum,  middle  ear,  or  the  periosteum,  spreads  from  a  point 
over  the  initial  lesion.  The  headache  may  be  confined  to  the  tem- 
poral, parietal,  occipital,  or  frontal  regions  on  one  or  both  sides,  or 
it  may  be  generally  distributed  throughout  the  whole  head.  It  has 
been  generally  conceded  that  migraine  is  unilateral,  but  other  con- 
ditions, such  as  uremia,  brain  tumor,  neurasthenia,  etc.,  may  also 
excite  a  unilateral  headache.  It  is  apparent,  therefore,  that  too 
much  reliance  in  making  a  diagnosis  of  the  causative  factor  or  fac- 
tors can  not  be  placed  upon  either  the  kind  of  pain  or  the  location. 

For  a  practical  working  basis,  I  agree  with  Leszynsky-  that  head- 
aches should  be  divided  in  two  classes  -  functional  and  organic.    Func- 

74 


HEADACHE  75 

tional  headaches  are  so  varied  and  so  frequent  that  to  classify  them 
is  almost  impossible.  In  this  group  are  included  those  headaches 
due  to  conditions  not  located  within  the  cranial  cavity.  Head- 
aches referable  to  various  constitutional  or  psychic  disturbances  are 
also  included  in  this  class. 

The  organic  form  includes  all  headaches  due  to  intracranial  dis- 
ease, or  disease  of  the  skull. 

Probably  the  most  frequent  form  of  functional  headaches  is  toxic 
in  nature.  Under  this  class  may  be  mentioned  as  exciting  causes 
(1)  operative  concern,  (2)  ether,  (3)  fatigue,  bad  air,  (4)  insola- 
tion, (5)  constipation  and  indigestion,  (6)  infections,  (7)  poisons, 
and  (8)  constitutional  diseases. 

Nervous  individuals,  and  those  patients  who  have  worried  over  the 
oncoming  operation,  frequently  develop  a  headache  before  etheriza- 
tion takes  place.  These  same  patients,  because  of  any  divergence  from 
the  routine  of  the  postoperative  treatment,  such  as  entertaining 
visitors,  sudden  anger,  disappointment,  or  what  not,  are  aften  no- 
ticeably victims  of  this  unpleasant  complication.  Ether  headaches 
very  soon  follow  the  narccsis,  but  do  not,  as  a  general  rule,  persist 
for  a  long  time.  Local  anesthesia  or  spinal  analgesia  are  more  lia- 
ble to  excite  this  symptom  than  ether,  and  the  effect,  in  my  experi- 
ence, is  far  more  lasting.  Fatigue  and  bad  air  do  not  go  hand  in 
hand,  though  the  association  is  so  common  in  these  patients  that  one 
can  hardly  resist  the  feeling  that  with  abundance  of  fresh  air  and 
sunlight,  fatigue  would  often  be  delayed.  Cabot  suggests  that  the 
fatigue  is  due  to  the  circulation  of  ''fatigue  poisons."  In  summer 
time,  especially,  and  following  a  "heat  wave,"  patients  develop 
headaches  which  seem  to  be  due  to  overheating.  Most  of  such  cases 
are,  more  or  less,  "nervous"  and  no  doubt  part  of  the  distress  is 
instigated  by  this  affection. 

The  absorption  of  the  excretory  products  of  the  body  or  fermen- 
tative or  decomposing  food  within  the  alimentary  canal  certainly 
plays  a  most  important  part  in  producing  this  condition.  Autoin- 
toxication from  this  source  was  long  ago  demonstrated  clinically  as 
a  very  productive  factor  in  causing  headaches.  One  of  the  first 
things  to  be  considered  in  the  treatment  of  the  condition  is  to 
thoroughly  eliminate  these  poisons  by  emptying  the  bowels  and  flush- 
ing the  kidneys.  Constipation  per  se  does  not  always  cause  a  head- 
ache, for  patients  very  often  go  many  days  and  even  a  week  with- 
out a  bowel  movement  without  symptoms.  On  the  other  hand,  others 
are  very  susceptible,  and  a  very  slight  irregularity  produces  severe 
headache.      Gastric    or   intestinal   indigestion   will   cause   headaches 


76  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

through  absorption  of  the  toxic  material  thus  generated,  through 
reflex  irritation  of  the  vagus  or  sympathetic  nerves,  or  from  gaseous 
distention  of  these  viscera,  due  to  the  abnormal  fermentation  of  the 
undigested  food.  Dizziness  frequently  accompanies  the  headaches 
produced  by  intestinal  intoxication,  and  the  urine  in  these  cases  will 
show  an  increase  in  the  indiean  reaction.  A  decrease  in  the  alka- 
linity of  the  blood,  as  seen  in  acidosis,  or  a  retention  in  the  blood  of 
excrementitious  substances,  as  seen  in  uremic  patients,  are  likely  to 
cause  persisting  and  severe  headaches,  which  are  relieved  only  when 
the  exciting  causes  are  reduced  by  elimination. 

Infection  or  inflammation,  accompanied  by  fever,  often  produces 
acute  headaches.  In  postoperative  cases,  it  is  usually  the  result  of 
catching  cold.  Rarely  it  is  the  symptom  of  some  acute  exanthema- 
tons  disease  superimposed  on  the  surgical  operation.  The  height  of 
the  fever,  the  character  of  the  pulse,  and  white  blood  count  are  im- 
portant adjuncts  in  making  a  diagnosis. 

The  withdrawal  of  poisons,  such  as  alcohol,  morphine,  tobacco, 
coffee,  etc.,  usually  exert  their  effects.  It  is  not  infrequently  seen  in 
patients  long  addicted  to  their  use.  ami  unless  the  demand  is  sup- 
plied, the  headache  becomes  persistent   and  quite  severe. 

Constitutional  diseases  such  as  gout,  diabetes,  chronic  rheumatism, 
or  hypothyroidism  may  cause  headaches  at  times. 

Another  form  of  functional  headache  comes  under  the  heading  of 
the  psychoneuroses.  This  includes  (1)  neurasthenia,  (2)  hysteria, 
and  (3)  epilepsy. 

Neurasthenia  is  fast  becoming  an  obsolete  term  for  vague  nervous 
affections,  which  apparently  have  no  cause  for  their  existence. 
Headaches  assumed,  or  in  most  of  the  cases  actually  experienced,  are 
peculiar,  in  that  so  often  only  a  fullness  in  the  head,  as  Leszynsky 
notes,  or  a  restricting  band  across  the  forehead.  The  disease  in- 
creases in  severity   with   the   increased   attention   given   the   patient. 

Hysterical  headaches  appear  suddenly,  and  apparently  are  very 
severe,  but  of  short  duration,  and  are  usually  localized.  Other  signs 
of  hysteria  may  accompany  the  symptom,  such  as  convulsive  attacks, 
muscular  spasms,  etc.,  the  condition  like  neurasthenia  is  very  favor- 
ably influenced  by  suggestion. 

Epileptics  frequently  develop  headaches  following  convulsions. 
Tins  symptom  occurred  regularly  in  one  of  my  patients,  the  condi- 
tion, however,  lasted  but  a  short  time,  but  the  number  of  convulsions 
could  be  accurately  ascertained  by  the  number  of  lime-  the  headache 
appeared. 

Functional    headaches   due   to    vasomotor   disturbances   are    fairly 


HEADACHE  77 

common.  Changes  in  the  atmosphere,  excessive  hard  mental  work 
or  worry,  insomnia,  venous  engorgement  from  chronic  heart  disease, 
coughing,  emphysema,  or  any  act  or  condition  resulting  in  obstruc- 
tion to  the  venous  return  in  the  neck,3  may  cause  the  onset  of  this 
unpleasant  symptom.  Cerebral  anemia  following  loss  of  blood  at 
operation,  as  a  result  of  posture,  shock,  or  arterial  disease,  is  very 
likely  to  produce  headache,  the  severity  and  duration  depending 
upon  the  extent  of  the  anemia. 

Migraine,  sick  headache,  or  hemicrania,  is  a  form  of  vasomotor 
headaches,  which  stands  alone  in  its  tenacious  persistence  and  se- 
verity of  symptoms.  It  is  said  that  the  immediate  cause  is  a  spas- 
modic contraction  of  the  cerebral,  or  other  arteries,  on  one  side  of 
the  head,  followed  by  unusual  dilatation  of  these  same  vessels.  The 
disease  is  usually  preceded  by  a  few  days  prodromal  symptoms  of 
lassitude,  irritability,  feeling  of  fullness  in  the  head,  etc. :  the  head- 
ache gradually  begins,  and  finally  reaches  a  severity  which  is  almost 
unbearable  for  the  patient.  One  side  of  the  head  is  involved  at  a 
time,  though  both  sides  may  become  alternately  affected.  The  attack 
lasts  several  hours,  and  at  times  several  days  elapse  before  the  pain 
disappears.  The  condition  is  a  periodic  inherited  one,  and  a  diag- 
nosis is  made  by  the  history,  character  of  the  attacks,  and  location 
of  the  pain. 

The  last  but  very  important  form  of  functional  headache  is  the 
reflex  type.  This  includes  the  affections  of  (1)  eye,  (2)  nose  and 
pharynx,   (3)  mouth,   (4)   ear,  also  (5)   gastric  and  menstrual  forms. 

Ocular  imperfections  are  such  a  common  source  of  headache  that 
they  must  be  seriously  considered  in  every  case  not  responding 
quickly  to  treatment.  Astigmatism  alone  is  one  of  the  most  common 
causes  of  persistent  headache.  It  is  usually  aggravated  by  overuse 
of  the  eyes.  Errors  of  refraction,  inflammation  of  any  part  of  the 
eyes,  iritis,  glaucoma,  etc.,  are  often  followed  by  headaches. 

Nasopharyngeal  obstructions,  inflammations,  deformed  septum, 
polyps,  etc.,  are  frequently  the  cause  of  headache,  and  especially  in 
the  chronic  mouth-breather. 

Carious  teeth  were  found  to  be  a  cause  of  persistent  headache  in 
one  of  my  cases.  On  removal  of  two  teeth,  the  headache  ceased  at 
once,  never  to  return. 

Impacted  cerumen  in  children  has  occasioned  a  disturbing  head- 
ache.   This  condition  has  not  been  observed  in  any  of  our  adult  cases. 

Gastric  conditions  producing  headache  have  already  been  men- 
tioned, but  reflex  hunger  pain,  exhibited  in  postoperative  patients, 


78  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

is  likely  to  be  followed  by  headache,  if  the  hunger  is  not  appeased 
within  a  short  time. 

Menstruation  is  a  common  cause  of  headache,  which  usually  oc- 
curs preceding  or  just  following  it.  It  is  not  a  hard  condition  to 
treat  as  a  rule. 

Cabot,  quoting  E dinger,  calls  attention  to  headache  which  has 
been  termed  "indurative"  and  is  associated  with  painful  uneven 
nodules  near  the  insertion  of  the  muscles  attached  to  the  occiput. 
When  these  nodules  disappear  under  massage,  the  headache  is  at 
once  relieved.  These  indurations  have  been  felt  in  a  few  of  our 
cases  after  operation,  and  in  each  case  they  were  accompanied  by 
headache  which  was  relieved  by  firm,  deep,  rotatory  massage.  The 
cause  of  the  condition  is  not  known,  and  so  far  as  I  have  been  able 
to  learn,  microscopic  examination  has  not  been  made  to  explain  the 
condition. 

The  organic  headaches  present  a  varying  number  of  causes. 
Among  the  first  to  consider  probably,  is  inflammation  or  disease  of 
the  frontal  or  ethmoid  sinuses.  The  pain  in  these  cases  is  most  severe 
in  front,  and  usually  worse  on  the  side  most  affected. 

Middle  ear  affections  and  disease  of  the  mastoid  are  frequently 
accompanied  by  headaches. 

Diseases  of  the  cranial  bones  or  inflammation  of  the  periosteum 
cause  localized  and  persistent  pain  at  times.  The  headache  is  more 
likely  to  be  worse  at  night.  Syphilitic  periostitis  is  always  a  likely 
exciting  cause  in  such  localized  affections. 

Intracranial  disturbances,  which  produce  headache,  such  as  in- 
flammation of  the  meninges,  particularly  inflammation  of  the  pia,  is 
very  likely  to  be  infective  in  nature.  However,  affections  of  the 
dura,  especially  in  old  people,  are  likely  to  be  due  to  syphilis.  This 
type  of  headache  is  commonly  periodical  and  paroxysmal  in  nature, 
worse  at  night,  and  there  is  usually  a  history  of  the  disease  for  long 
periods  of  time.  Cerebral  syphilis  produces  endarteritis,  with  gum- 
matous formation,  either  on  the  meninges  or  within  the  brain  sub- 
stance. In  addition  to  the  headache,  other  symptoms  occur,  such 
as  vomiting,  paralyses,  optic  neuritis,  and  possibly  vertigo. 

Intracranial  tumors,  other  than  gummata,  are  exciting  causes,  at 
times,  of  persistent  and  severe  headache.  The  pain  usually  is  some- 
where near  the  location  of  the  tumor,  but  occasionally  the  pain  is 
general.  Psychic  excitement,  stimulation  of  any  kind,  straining  at 
stool  or  coughing,  etc.,  always  aggravates  the  condition. 

The  general  diagnosis  of  the  cause  of  headaches  is  extremely  dif- 
ficult in  a  large  number  of  cases,  and  there  is  a  still  greater  mini- 


HEADACHE  79 

ber  of  postoperative  headaches  in  which  a  diagnosis  is  not  made  at 
all.  These  cases  represent  so  large  a  number  that  it  is  discourag- 
ing to  even  attempt  the  enumeration  of  known  causes. 

Of  cases  which  do  not  clear  up  under  ordinary  treatment,  and  in 
whom  the  etiology  is  obscure  I  would  suggest  that  Cabot's  follow- 
ing question  be  asked:  ''(a)  Is  the  headache  of  paroxysmal  occur- 
rence and  fixed  duration  (usually,  twelve  to  twenty-four  hours), 
accompanied  by  disturbances  of  vision  and  great  prostration  (mi- 
graine) ?  (b)  Is  the  history  that  of  a  psychoneurosis  ?  (c)  Does  the 
pain  recur  at  precisely  the  same  hour  each  day?"  In  addition  to 
the  general  physical  examination  and  blood  for  \Vassermann  in  sug- 
gestive cases,  he  would  add  the  following:  "Examination  of  the 
eyes  (including  retinoscopy),  (2)  blood  pressure  determination 
(nephritis,  tumor),  (3)  temperature  record  (infections),  (4)  uri- 
nalysis (albumin,  sugar,  acetone),  (5)  examination  of  the  nose  and 
its  accessory  sinuses  and  (6)  palpation  of  the  insertion  of  the  nape 
muscles  at  the  occiput." 

The  treatment  consists  first  in  an  earnest  attempt  at  diagnosis. 
As  Schreiber4  says:  "Each  headache  has  a  different  meaning,  and 
when  one  considers  that  all  the  infectious  diseases  begin  with  head- 
ache, it  is  one  of  the  most  important  symptoms  with  which  we  deal." 

"Abrams3  says  that  while  the  diagnosis  is  being  attempted,  the  pa- 
tient should  be  palliatively  treated.  Certain  preventive  measures 
can  be  carried  out  in  surgical  cases.  During  an  operation  the  brain 
is  being  continually  stimulated  by  the  cutting  of  tissues  and  nerves 
which  have  not  been  blocked."  Schreiber  thinks  this  a  very  impor- 
tant cause  in  postoperative  headaches,  and  in  patients  subject  to  this 
malady,  nerve  blocking  may  be  attempted  before  the  operation  be- 
gins. At  the  end  of  the  operation  the  stomach  should  be  washed 
thoroughly  with  cool  water,  which  not  only  cleans  out  the  irritating 
ether  mucus,  but  also  gives  tone  to  the  more  or  less  dilated  stomach. 
The  patient  is  then  put  into  a  warm  bed.  and  kept  comfortable. 
Surgical  shock  is  another  important  cause  of  postoperative  head- 
ache which  Schreiber  would  overcome  by  the  simple  measures  above. 
If  headache  occurs  in  spite  of  the  preventive  measures  suggested, 
the  first  attempt  at  treatment  is  to  get  the  head  cool  with  ice  bags 
or  cold  cloths.  This  causes  a  constriction  of  the  vessels  in  the  be- 
ginning, followed  by  a  dilatation  of  the  vessels.  At  this  stage,  if 
the  patient  so  desires  it,  the  ice  cap  can  be  replaced  by  the  hot-water 
bag.  The  feet  are  kept  hot  by  means  of  hot-water  bags,  from  the 
beginning  of  the  attack,  and  measures  begun  to  thoroughly  clear  the 
gastrointestinal  tract. 


80  AFTER-TREATMENT    OP    SURGICAL    PATIENTS 

Large  doses  of  phenacetin,  acetanilid,  aspirin,  etc.,  which  so  often 
are  next  in  order,  are  not  particularly  subscribed  to  by  Schreiber, 
since  they  are  so  likely  to  depress  the  circulation.  He  would  use  in- 
stead, bromides  which  arc  very  efficient  in  allaying  the  reflexes  and 
thus  are  very  useful  in  the  migraine  form  of  headache.  Migrainin, 
a  mixture  of  antipyrine  with  caffeine  and  citric  acid,  in  doses  of  10 
to  15  grains  is  also  wry  useful. 

In  some  instances  adrenalin  10  to  20  minims,  may  be  given  hypo- 
dermically.     This  drug  occasionally  causes  vomiting. 

The  congestive  forms  of  headache,  those  dim  to  arteriosclerosis  or 
locomotor  ataxia  respond  particularly  well  to  concussion  of  the 
seventh  cervical  vertebra.  Clinically  this  produces  a  vasoconstric- 
tion of  the  vascular  system  throughout  the  body,  and  especially  that 
of  the  head.  Schreiber  states  that  the  results  are  marked  and  by 
examining  the  fundus  of  the  eye  at  this  time,  the  vessels  can  be  seen 
to  constrict.  He  used  this  method  successfully  in  relieving  a  head- 
ache due  to  a  cerebellar  tumor,  which  could  not  be  removed  at  op- 
eration. Concussion  of  the  tenth  dorsal  vertebra,  however,  causes  a 
dilatation  of  the  vascular  system,  and  is  attempted  in  cases  which 
indicate  such  therapy.  The  method  should  not  he  employed  until 
the  other  measures  have  been  tried.  The  claims  are  based  on 
clinical  observations  alone. 

To  concuss  the  spine,  an  instrument  especially  devised  by 
Schreiber,  is  placed  directly  over  the  spinous  process  of  the  vertebra 
and  then  struck  a  firm  blow  with  a  rubber  hammer,  which  is  rein- 
forced with  wood.  The  blow  is  repeated  ten  times,  after  which  a 
rest  equal  to  five  blows  is  enjoined,  and  then  the  process  is  again 
repeated.  This  is  continued  for  three  to  five  minutes.  The  treat- 
ment can  be  repealed  ^\vvy  three  to  four  hours,  and  kept  up  as  long 
as  necessary. 

"In  that  type  of  headache  which  seems  to  involve  the  region  of  the 
occipital  nerve,  AJbrams  finds  the  most  tender  point  along  the  nerve 
by  means  of  linn  pressure  with  some  hard  instrument,  and  then 
freezes  it  for  three  to  five  minutes  with  ethyl  chloride.  In  diabetics 
or  very  run-down  individuals,  it  is  not  frozen  so  lone  because  of  the 
danger  of  skin  necrosis."  Schreiber  would  repeat  this  treatment  as 
often  as  the  headache  returns. 

Finally,  codeine  or  morphine  may  he  resorted  to  if  no  relief  can 
lie  obtained  by  the  above  measures.  Stewart,  however,  would  try 
to  bring  about  sleep  with  the  bromides  and  veronal  or  chloral,  before 


HEADACHE  81 

the  opium  is  administered.  Opium  certainly  should  not  be  used  for 
this  condition,  since  opium  addiction  is  particularly  liable  to  develop 
in  such  patients. 

Bibliography 

iCabot:     Differential  Diagnosis,  1916,  p.  37. 

2Leszynskj:     Eeference  Handbook  of  the  Medical  Sciences,  1902,  iv,  547. 

sStewart:      The    Practitioner's    Encyclopedia    of    Medical    Treatment,    1915,    p. 

428. 
■iSehreiber,  Louis :     Personal  communication. 
5A.brams:     Quoted  by  Schreiber. 


CHAPTER  XI 

BACKACHE 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Backache  is  a  symptom  commonly  complained  of  the  day  following 
a  surgical  operation.  In  fact  many  patients  give  one  the  impression 
that  this  is  their  most  distressing  symptom.  It  is  increased  usually 
when  the  patient  turns  in  the  bed  or  in  any  manner  twists  the  back 
or  uses  the  muscles  of  this  region.  The  pain  is  located  in  either  the 
lumbar  or  sacral  regions  or  both,  and  is  often  accompanied  by  ri- 
gidity of  the  lumbal-  muscles  as  noted  by  Da  Costa;1  the  pain  may 
persist  for  many  days,  being  a  fruitful  source  of  annoyance  and  even 
wakefulness  in  the  patient. 

I  believe  I  have  heard  this  complaint  by  two  classes  of  patients 
particularly  (a)  those  who  have  had  a  general  anesthesia  (b)  those 
who  were  lying  flat  on  the  back  during  the  operation.  This  ob- 
servation gives  color  to  the  theory  that  the  normal  curve  of  the  spine 
is  maintained  by  the  muscles  and  ligaments  acting  together,  hence 
deep  anesthesia,  by  relaxing  the  muscles,  imposes  an  undue  load  on 
the  ligaments  which  are  stretched  beyond  the  normal  degree  if  the 
patient  lies  on  a  perfectly  flat  table.  Severe  backache  is  the  result. 
Other  etiologic  factors  have  been  propounded  by  various  observers. 
Among  these  may  be  mentioned  renal  congestion,  congestion  of  the 
spinal  cord,  etc.  Dunlap2  states  that  the  position  of  the  patient  on  a 
hard  flat  table  without  a  support  causes  undue  strain  on  the  sacro- 
iliac synchondrosis,  while  Kosmark3  considers  the  strain  on  the  lum- 
bar ligaments  the  paramount  cause  of  backache  in  these  cases. 

Backache  existing  in  patients  longer  than  the  first  few  postopera- 
tive days  is  a  matter  which  demands  more  thorough  attention  than 
is  usually  given  these  sufferers.  I  have  seen  the  malady  persist  for 
weeks,  bringing  about  serious  delay  in  the  convalescence  and  at  the 
same  time  inviting  condemnation  of  the  surgeon  by  the  patient,  until 
the  cause  of  the  condition  was  Hound  and  the  correct  treatment  in- 
stituted. In  these  instances  the  backache,  probably  first  started 
by  the  position  on  the  table,  is  kept  up  by  other  causes  and  condi- 
tions. 

Diseases  long  before  cured  and  which  had  previously  given  severe 
trouble  with  the  back  may  have  been  started  anew  by  the  operative 

82 


BACKACHE  83 

procedure.  This  symptom  which  may  have  been  prominent  before 
the  operation  (which  was  probably  performed  for  an  entirely  differ- 
ent malady)  may  cause  such  severe  pain  that  the  postoperative  care 
resolves  itself  into  the  treatment  of  the  backache  alone.  The  malady 
is  so  commonly  observed  during  the  after-care  of  surgical  patients 
that  its  cause  whether  due  to  the  operative  procedure  or  some 
chronic  ailment  of  the  patient  must  be  determined  and  measures 
undertaken  to  alleviate  the  distress  thereby  produced.  The  back- 
ache may  not  even  be  mentioned  by  the  patient  until  he  is  allowed 
out  of  bed.  It  matters  little  to  the  patient  whether  the  pain  is 
rightfully  a  postoperative  complication ;  it  is  a  condition  to  be  suc- 
cessfully met  by  the  doctor  in  charge  of  the  case  and  a  systematic 
study  of  the  condition,  therefore,  can  hardly  be  overlooked  in  a  work 
of  this  kind. 

The  lumbar  or  sacral  backache  when  not  due  to  any  of  the  causes 
mentioned  above  may  result  from  the  added  strain  of  the  operation 
on  a  neurasthenic  type  of  patient  whose  general  vitality  may  be  so 
lowered  as  to  seriously  affect  the  nerve  tone.  In  such  patients,  par- 
ticularly of  the  female  sex,  Kosmark  calls  attention  to  the  fact  that 
any  pelvic  condition  such  as  inflammations,  exudates,  tumors,  uter- 
ine displacements,  constipation,  etc.,  may  result  in  backache.  Even 
in  those  individuals  not  so  run  down  or  upset  by  the  operation, 
pathologic  pelvic  conditions  such  as  those  mentioned  above  are  ex- 
tremely important  etiologic  factors  and  this  possibility  must  not  be 
overlooked  in  patients  who  are  suffering  from  backache  and  who 
were  not  subjected  to  a  pelvic  or  gynecologic  operation. 

During  the  menstrual  period,  I  have  often  noted  an  increase  in  the 
severity  of  the  symptoms  in  an  already  aching  back  or  a  beginning 
of  this  malady  in  patients  previously  free  of  pain.  In  the  latter 
instances  the  backache  usually  disappeared  with  the  menses.  Oper- 
ations upon  pregnant  women  are  very  likely  to  be  followed  by  severe 
backache.  In  my  experience  I  have  not  found  adequate  means  to 
prevent  this  malady  regardless  of  the  treatment  and  care  afforded 
such  patients  on  the  operating  table.  "Williams4  and  others  have 
noted  the  physiologic  relaxation  of  the  various  pelvic  joints  during 
pregnancy  and  Goldthwait  and  Osgood5  state  that  possibly  always — 
certainly  occasionally,  during  menstruation — this  state  of  affairs  ex- 
ists. There  has  accumulated  considerable  evidence  to  prove  that  the 
pelvic  articulations,  particularly  the  sacroiliac  synchondroses  are 
true  joints,  having  all  the  common  joint  structures  as  stated  by  Gold- 
thwait and  O-sgood  and  "that  this  being  the  ease,  they  are  naturally 
subject  to  the  same  diseases  and  injuries  as  the  other  joints.    When 


84  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

this  is  once  appreciated  and  the  character  of  the  articulations  is 
considered,  and  especially  when  it  is  remem'bcred  that  the  exact  op- 
position of  these  is  maintained  almost  entirely  by  the  ligaments,  the 
surprising  thing  is  not  that  abnormal  mobility  and  disease  of  the 
joints  ever  do  occur  but  that  they  do  not  occur  more  frequently." 
In  view  of  these  findings  it  is  not  surprising  that  backache  should 
occur  often  in  this  class  of  cases  following  the  added  strain  on  the 
ligaments  from  muscular  relaxation  due  to  the  general  anesthetic 
alone,  to  say  nothing  of  any  malposition  the  patient  may  have  as- 
sumed during  the  operation. 

In  studying  the  cause  of  backache,  trauma  is  a  factor  not  to  be 
lightly  turned  aside.  I  once  knew  of  a  patient  aged  twelve  upon 
whom  a  tonsillectomy  and  adenoid  operation  was  performed,  who 
suddenly  the  next  day  developed  a  most  severe  backache  which  ne- 
cessitated several  days'  stay  in  bed.  It  was  finally  learned  after 
most  thorough  examination  that  the  patient  had  fallen  out  of  bed 
during  the  previous  night.  The  operative  procedure  was  carried  out 
at  the  patient's  home  and  was  not  in  the  care  of  a  nurse.  This  prob- 
ably accounted  for  the  accident.  Other  instances  have  been  brought 
to  our  attention  where  the  patient  sat  down  too  hard  or  had  fallen 
on  the  hard  hospital  floor. 

In  discussing  other  etiologic  factors  (ioldthwait  and  Osgood  fur- 
ther state  that  ''a  mere  general  lack  of  physical  tone  naturally  pre- 
disposes to  trouble  of  this  sort,  the  bones  are  held  in  place  almost 
entirely  by  ligaments  and  it  is  not  to  be  wondered  at  that  these  re- 
lax and  cause  trouble  as  do  ligaments  of  the  knee  or  foot  under 
similar  conditions. 

"In  cases  in  which  definite  disease  is  present  the  same  elements 
which  predispose  to  the  special  type  of  lesion  in  other  joints  nat- 
urally favor  the  occurrence  of  the  same  type  in  the  articulations  of 
the  pelvis. 

"Tuberculosis  has  long  been  known  to  occasionally  develop  in 
these  joints.  The  in  feet  ions  form  of  arthritis  may  also  extend  to  the 
pelvis  in  connection  with  the  more  general  manifestation  of  the  dis- 
ease. The  same  thing  is  true  of  the  atrophic  or  the  hypertrophic 
forms  of  arthritis,  although  the  latter  is  by  far  the  more  common. 
It  is  in  this  hypertrophic  form  that  the  joints  at  times  become  en- 
tirely fused  and  that  the  persistent  sciatica  or  leg  pains  are  so  com- 
monly seen.  These  referred  pains  are  probably  due  to  the  pressure 
of  the  hypertrophic  tissue  upon  the  lumbosacral  cord  as  it  passes 
over  the  articulation." 

Epstein6  calls  attention  to  these  same  diseases,  however,  affecting 


BACKACHE  85 

the  spinal  column,  as  a  cause  of  backache.  He  ventures  the  state- 
ment that  the  general  surgeon  has  removed  appendices,  ovaries  and 
performed  other  laparotomies,  where  the  patient  might  have  been 
much  better  served  by  a  spinal  support  or  plaster  jacket.  As  a  mat- 
ter of  fact  such  a  mistake  was  made  in  Bartlett's  clinic  re- 
cently. A  male  patient,  aged  41,  was  admitted  for  pain  in  lower 
abdomen  and  back.  A  diseased  appendix  was  removed,  but  this  in 
no  way  alleviated  his  complaint.  On  closer  examination  after  the 
patient  had  had  severe  backache  for  a  week,  a  hypertrophic  arthri- 
tis was  discovered  in  the  lumbar  vertebra  with  absolute  immov- 
ability in  three  of  them.  A  plaster  of  Paris  jacket  was  applied  with 
perfect  relief  of  all  symptoms. 

In  the  elimination  of  the  various  causes  of  backache  which  a  post- 
operative patient  may  present,  gout  must  not  be  forgotten.  Myal- 
gia of  the  lumbar  muscles  (lumbago)  is  another  source  for  this  symp- 
tom. The  etiology  is  obscure  though  it  often  occurs,  according  to 
some  observers,  in  patients  with  rheumatic  predispositions.  In  con- 
sidering lumbago,  one  must  differentiate  from  any  early  osteomalacia. 
\Veinstein7  states  that  if  this  latter  disease  is  present,  there  will  be 
a  waddling  and  uncertain  gait  and  a  shortening  of  the  patient's  stat- 
ure. Continuing  this  subject  AVeinstein  notes  that  "the  rhachialgia 
of  neurasthenia  simulates  lumbago,  but  the  etiologic  features  of  the 
latter  disease  are  absent,  and  there  is  no  aggravation  of  pain  on 
straining,  while  there  is  usually  exacerbation  under  emotion.  Myosi- 
tis, with  gradual  onset,  presents  stiffness  or  rigidity  in  the  extremi- 
ties and  back.  The  pains  are  vague  for  a  while,  when  they  take  on 
a  more  definite  character  and  become  localized  in  various  muscle 
groups.  As  the  muscular  involvement  rapidly  becomes  general,  skin 
lesions  and  edema  develop,  the  true  character  of  the  condition  is 
soon  appreciated.  Malignant  tumors  of  the  cord,  such  as  carcinoma, 
sarcoma,  and  myeloma,  give  rise  to  pressure  symptoms,  the  signif- 
icance of  which  can  not  long  be  doubted." 

A  floating  kidney  may  also  give  rise  to  backache,  especially  if  as- 
sociated with  a  general  splanchnoptosis.  This  latter  abnormality 
alone  will  give  rise  to  severe  backache  in  the  patient  out  of  bed.  The 
"enteroptotic  habitus"  of  Mills,  and  the  nervous  and  dyspeptic  dis- 
orders will  help  one  to  claim  this  condition  as  the  cause  of  the  com- 
plaint. 

Occasionally  gallstone  colic  occurs  in  the  convalescing  patient  who 
has  been  operated  for  some  other  ailment.  Pain  in  the  right  shoulder 
region  remains  after  the  attack  has  subsided.  An  engorged  liver,  a 
pyloric  stenosis,  or  mediastinal  tumors  may  cause  backache  accord- 


86  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

ing  to  Weinstein.  He  also  calls  attention  to  thoracic  or  abdominal 
aneurysms  as  a  cause  in  some  instances.  Neuritis  even  that  pro- 
duced by  glycosuria  may  be  a  fruitful  factor  in  producing  back- 
ache. 

A  pelvic  or  ureteral  calculus  or  kidney  neoplasm  gives  rise  to 
severe  backache  at  times.  Wollheim8  states  that  the  frequency  of  the 
malady  diminishes  as  the  tract  is  ascended.  He  also  notes  that  in 
obscure  cases  of  backache,  masturbation  must  be  considered  an  etio- 
logic  possibility. 

Attitudes  or  postures  play  an  important  role  in  backache  as  has 
been  noted  by  many  observers.  Goldthwait  and  Osgood  stated  with 
reference  to  the  pelvic  articulations  that  "when  once  it  is  appreci- 
ated that  motion  in  these  articulations  normally  exists,  it  is  easily 
understood  that  such  attitudes  as  standing  with  extreme  lordosis,  or 
sitting  with  the  lumbar  curve  reversed,  as  in  lounging,  must  cause 
strain  on  the  sacroiliac  articulations,  which  if  continued  will  result 
in  the  same  weakness  and  relaxation  as  is  seen  in  any  of  the  other 
joints  under  like  conditions  of  strain.  In  stout  persons,  either  men 
or  women,  the  drag  of  the  large  abdomen  causes  lordosis  with  result- 
ing pelvic  joint  strain  and  explains  the  frequency  of  the  sacroiliac 
weakness  in  this  type  of  individual." 

The  weight  of  large  tumors  will  cause  their  presence  to  be  felt 
very  likely  in  some  sort  of  hack  pain.  I  had  one  ease  of  elephantiasis 
of  the  right  breast  which  gave  increasing  symptoms  of  pain  and 
backache  in  the  thoracic  and  Lumbar  portions  of  the  spine.  Support 
of  the  enlarged  breast  gave  only  temporary  relief.  Permanent  cure 
for  the  condition  was  the  removal  of  the  tumor.  The  patient  was  ad- 
mitted for  a  hemorrhoid  operation,  but  the  backache  was  so  severe 
that  other  operative  measures  were  necessary  first  to  relieve  the 
severe  symptoms. 

Backache  due  to  the  changes  in  the  position  of  the  fifth  lumbar 
vertebra  condition  called  by  Killian,0  spondylolisthesis  is  more  com- 
mon than  is  probably  supposed.  Lane10  considered  the  malady  in 
coal  heavers  a  normal  finding  and  stated  that  it  was  indeed  common 
among  the  laboring  classes. 

Neugebauer,11  who  has  given  more  attention  to  this  subject  than 
anyone  else,  thought  the  condition  was  produced  by  a  thinning  of  the 
interarticular  portions  of  the  last  lumbal'  vertebra  as  a  result  of  im- 
proper development  or  fracture  of  this  portion.  Others  have  since 
shown  that  it  can  occur  from  fracture  of  the  articular  processes  with- 
out the  changes  in  the  vertebra.  Lane  considered  in  some  cases,  at 
least,  that  the  change  in  the  interarticular  portion  is  caused  by  ex- 


BACKACHE  87 

cessive  pressure.  Golclthwait12  has  shown,  however,  that  the  condi- 
tion can  occur  without  any  destruction  in  the  interarticular  portion. 
In  such  cases  he  states  that  because  of  the  various  shapes  and  fac- 
ings of  the  superior  articular  processes  of  the  first  sacral  segment, 
unlocking  takes  place,  allowing  the  fifth  lumbar  vertebra  to  slip  for- 
ward. It  is  not  the  marked  forms  of  spondylolisthesis  but  the 
slighter  forms,  difficult  or  impossible  to  diagnose,  which  are  to  blame 
for  some  of  the  obscure  continued  postoperative  backache. 

Golclthwait  also  notes  as  a  cause  of  some  back  pain,  the  variations 
in  length  and  shape  of  the  transverse  processes  of  the  fifth  lumbar 
vertebra  and  that  in  the  height  of  the  superior  aspects  of  the  lateral 
portions  of  the  sacrum.  In  some  cases  one  of  the  processes  is  so  long 
as  to  even  join  the  sacrum.  In  this  connection  Goldthwait  states 
that  ' '  if  the  process  were  fused  to  the  sacrum  there  would,  of  course, 
be  no  motion  at  this  point.  If  it  were  free  the  impinging  of  the  end 
of  this  process  against  the  top  of  the  sacrum  (often  forming  a  true 
joint),  or  the  posterior  part  of  the  ilium,  would  not  only  limit  the 
motion,  but  also,  if  repeated,  would  result  in  sensitiveness  at  the 
point  of  contact." 

Another  cause  for  backache,  particularly  that  seen  in  patients 
who  have  just  got  out  of  bed  for  the  first  time  after  a  prolonged  stay, 
is  postoperative  flat-foot. 

It  has  been  known  for  some  time  that  an  extended  stay  in  bed  will 
so  weaken  the  muscles  ami  ligaments  of  the  leg  as  to  produce  the 
typical  flat-foot.  This  is  more  common  in  those  cases  where  exten- 
sion of  the  leg  from  fracture,  etc.,  has  been  maintained  without  ade- 
quate support  to  the  ball  of  the  foot.  Ogilvy13  in  discussing  the 
subject  of  weak  feet  states  that  it  "may  or  may  not  be  accompanied 
by  painful  symptoms  in  the  feet.  The  symptoms  are  those  of  a  tired, 
aching  feeling,  referred  to  the  lumbar  spine,  and  are  noted  after  the 
patient  has  stood  on  the  feet  for  some  time."  An  increase  in  the 
amount  of  standing  or  walking  will  increase  the  pain  Ogilvy13  says, 
while  rest  always  relieves  the  pain.  Continuing,  Ogilvy  notes  that 
"upon  examination  of  the  back  alone,  there  is  little  evidence  of  the 
cause  of  the  pain.  The  spine  is  freely  movable.  There  is  no  spasm 
of  muscle  or  any  other  sign  of  any  inflammatory  lesion,  nor  is  there 
any  tenderness  on  pressure,  nor  deformity.  The  cause  of  the  trou- 
ble is,  therefore,  likely  to  be  overlooked,  unless  the  feet  are  thought 
of  and  an  examination  of  them  made.  These,  when  examined,  are 
found  to  be  everted.  When  questioned,  the  patient  admits  that  the 
feet  tire  easily,  are  sometimes  painful,  and  that  the  pain  at  times 
extends  up  the  leg.  It  is  of  the  greatest  importance  to  examine  such 
feet  with  the  patient  standing,  and  it  is  of  just  as  great  importance 


OO  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

to  remember  that  flat  feet  are  not  necessary  to  account  for  the  back- 
ache caused  by  foot  strain.''  In  giving  the  cause  of  backache,  even 
though  the  feet  are  found  defective,  Ogilvy  states  that  the  "'proper 
foot  balance  is  lost  and  the  body  poise  is  so  changed  as  to  throw  an 
excessive  weight  strain  on  the  muscles  and  ligaments  in  the  back, 
producing  a  dull,  boring  pain,  which  increases  in  severity  as  the 
patient  continues  to  overstrain  these  structures  in  standing  or  walk- 
ing. When  the  foot  balance  is  corrected  and  the  foot  strain  re- 
lieved, the  backache  is  immediately  cured." 

In  some  cases  after  all  the  possible  causes  mentioned  above  have 
been  eliminated  and  the  condition  still  remains  unexplained,  it  has 
been  suggested  by  most  of  the  writers  on  the  subject  that  there  must 
be  some  peculiarity  in  development  which  diminishes  the  stability 
of  the  lumbar  and  pelvic  articulations. 

Coccygodynia  is  associated  with  backache  in  these  cases  at  times. 
Pain  in  and  around  the  region  of  the  coccyx  is  also  noted  independ- 
ently of  backache.  The  affection,  peculiar  to  women,  presents  un- 
mistakable clinical  features,  hut  so  far  as  I  know  there  is  no  definite 
pathologic  condition.  The  symptom  more  often  appears  in  married 
patients,  particularly  those  who  have  borne  children,  although  it  oc- 
curs in  unmarried  females.  I  do  not  recall  a  single  case  where  it 
developed  in  a  postoperative  male  patient.  A  history  of  injury  is 
given  in  most  of  the  eases  although  in  two  very  typical  cases  occurring 
in  our  patients,  no  such  etiologic  factor  eould  be  elicited.  In  each  pa- 
tient there  was  a  definite  neurasthenic  hasis  upon  which  I  could  place 
the  cause  of  the  condition.  The  pain  complained  of  was  sharp  shoot- 
ing and  was  intensified  on  sitting  up  in  bed.  sudden  rising,  or  during 
the  act  of  defecation. 

In  the  treatment  of  pure  postoperative  backache  preventive  meas- 
ures are  more  important  than  the  after  cure,  hence  one  will  readily 
appreciate  the  value  of  a  well-padded  table  which  conforms  as  nearly 
as  possible  to  the  outline  of  the  spinal  column.  When  the  patient  re- 
turns to  hed  a  roll  placed  cinder  the  hack,  frequent  turnings  and  al- 
lowing the  patient  to  move  of  his  own  accord  will  often  aid  in  prevent- 
ing a  seven-  backache.  In  other  cases  the  malady  will  occur  no  matter 
what  efforts  have  been  put  forth  to  offset  it.  When  it  does  appear, 
massage,  alcohol  rubs  and  heat  may  be  applied  with  marked  success. 
The  lumbar  spine  should  he  supported  with  bed  rolls,  pillows,  and 
other  simple  measures  employed  to  take  as  much  strain  off  the  lum- 
bal- ligaments  as  possible.  We  are  usually  aide  to  gain  hut  a  slight 
measure  of  relief  from  change  of  position,  although  it  may  also  be 
tried.     The  patient  must  not  be  allowed  to  suffer  from  this  condition 


BACKACHE  89 

during  the  first  few  days  of  his  convalescence.  Among  the  medi- 
cines used  to  give  comfort  to  such  patients  none  seem  to  give  the  re- 
lief that  some  form  of  opium  combined  with  the  salicylates  will  ac- 
complish. Usually  I  employ  codeine  y2  to  1  grain  with  aspirin,  5  to 
10  grains  and  repeat  the  codeine  within  one  hour  if  the  pain  is  not 
relieved  at  once.  Warm  plain  water  enemas  to  be  retained  as  long 
as  possible  and  hot  fluids  per  mouth  are  also  used  in  some  cases  with 
great  measures  of  success.  The  bowels  and  bladder  are  kept  empty 
during  the  active  treatment.  The  urine  is  watched  for  sugar  and 
general  eliminative  measures  carried  out. 

When  the  symptom  is  produced  by  some  gynecologic  disorder, 
the  condition  is  met  as  soon  as  practical  by  methods  accepted  by  the 
best  authorities  for  the  individual  disease. 

The  treatment  given  in  individual  cases  depends  upon  the  extent 
of  the  lesion  producing  the  symptoms.  In  every  case  the  important 
factor  is  the  diagnosis  and  if  the  case  presents  unusual  findings  the 
orthopedist,  the  neurologist,  or  the  internist  should  be  asked  in  con- 
sultation and  treatment  carried  cut  as  directed  by  either  of  them. 

For  acute  strain  of  the  pelvic  articulations  adhesive  strips  two 
inches  wide  are  placed  from  the  anterior  portion  of  the  ilium  on 
the  one  side  to  a  similar  position  on  the  other  side.  The  strips  are 
overlapped  and  continued  to  be  placed  until  the  whole  lumbosacral 
region  is  covered.  A  pad  of  felt  over  the  sacral  region  will  often 
be  appreciated  as  a  more  or  less  subluxation  of  the  sacrum  occurs  in 
these  cases.  Golclthwait  and  Osgood  state  that  in  relaxed  pelvic  ar- 
ticulations frequently  there  is  not  correct  opposition  in  the  bones,  the 
malposition  being  a  true  backward  displacement  of  the  sacrum  in  its 
upper  part.  They  would  correct  such  a  malady  by  "hyperextending 
the  spine  by  means  of  firm  pillows  under  the  lumbar  curve  or  hav- 
ing the  patient  lie  face  downward  with  only  the  legs  and  thighs  sup- 
ported upon  the  table  and  the  head  and  shoulders  upon  another,  the 
body  hanging  entirely  unsupported  between.  In  this  position  the 
weight  of  the  body  drags  the  spine  forward,  which  favors  the  re- 
placement of  the  sacrum.''  A  plaster  of  Paris  jacket  is  now  applied 
while  the  patient  is  in  this  position.  It  may  be  advisable  to  place 
the  patient  upon  the  frame  as  shown  in  (Fig.  152,  page  467)  which 
will  allow  of  more  sacral  pressure.  A  spica  including  both  thighs  may 
become  necessary  in  order  to  hold  the  pelvic  bones  in  place  after  they 
have  once  slipped  back  from  the  malposition  due  to  the  relaxation  of 
the  ligaments.  Goldthwait  and  Osgood  would  keep  such  patients  in 
bed  four  weeks,  then  allow  them  to  be  out  with  some  sort  of  remov- 
able jacket  which  is  to  be  worn  three  months  longer.     The  jacket,  the 


90  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

authors  say,  should  fit  well  down  over  the  trochanters  and  be  made 
of  stiffened  leather  or  plaster  of  Paris  and  applied  with  the  patient 
standing  and  the  lumbar  spine  moderately  extended. 

In  the  relaxations  without  displacement  (and  these  represent  the 
largest  number  according  to  my  own  observation)  the  adhesive  strap- 
ping of  the  back  and  the  jacket  stated  above  are  entirely  sufficient. 
At  night,  when  the  pain  is  particularly  severe,  supports  in  the  form 
of  a  bed  roll  under  the  lumbar  curve  or  under  the  side  if  the  patient 
wants  to  lie  in  this  position  may  be  used. 

The  cases  presenting  symptoms  due  to  tuberculosis,  hypertrophic 
arthritis,  trauma,  lumbosacral  disturbances,  abnormal  spinous  proc- 
esses,  etc.,  are  treated  by  immobilization  or  in  some  cases  even  opera- 
tion then  followed  by  immobilizing  measures. 

In  the  treatment  of  coccygodynia  the  same  general  measures  as 
noted  above  may  also  be  employed.  Hot  sitz-baths.  massage,  and  ef- 
forts put  forth  to  discard  any  movement  which  will  in  any  way  ag- 
gravate the  condition,  are  to  be  employed.  The  treatment,  however, 
is  generally  unsatisfactory.  At  times  the  coccyx  has  been  removed 
even  without  relief.  Lippens14  recently  advised  the  injection  of  0.5 
c.c.  of  50  per  cent  solution  of  antipyrin  in  alcohol  into  the  third  and 
fourth  sacral  nerves.  In  carrying  out  the  technic  Lippens  points 
out  that  the  point  of  exit  of  the  third  sacral  nerve  is  an  inch  outside 
of  the  crest  of  the  sacrum  and  an  inch  below  the  posterior  inferior 
spine  of  the  ilium;  that  of  the  fourth  sacral  nerve  is  a  fingerbreadth 
lower.     The  treatment  is  worthy  of  trial  in  intractable  cases. 

Bibliography 

iDaCosta:     Modern  Surgery,  1014,  p.  1206. 

zDunlap:     New  York  Med.  Jour.,  1909,  xl.  64. 

sKosmaik:     New  York  Med.  Jour.,  1915,  eii,  5091. 

*Williams:     Obstetrics,  1912,  p.  511. 

sGoldthwait  and  Osg 1:     Boston  Med.  and  Surg.  Jour.,  1905,  clii.  5-95. 

^Epstein:     New  York  Med.  Jour.,  1915,  eii,  761. 

"Weinstein:      New  York  Vied.  Jour.,  1915,  eii,  707. 

BWollheim:     Am.  Jour.  Surg.,  1915,  xxix,  406. 

"Killian:     .Quoted  by  Williams. 

loLane:     Trans.  London  Path.  Soc.  1885,  xxxvi.  :;<'>l-:;7v 
uNeugebauer :     Monatschr.  f.  Geburtsh.,  u.  Gymik..  1895,  i.  ::i 7-347. 
i2Goldthwait :     Boston  Med.  and  Surg.  Jour.,  1911,  clxiv,  365. 
isOgilvy:     New  York  Med.  Jour..  1914.  e,  1107. 
i^Lippens:      Gaz.  de.  Gynec,  Paris.   1914,  xxix,   177. 


CHAPTER  XII 

SHOCK 
By  Willard  Bartlett,  St.  Louis,  Mo. 

An  historical  account  of  the  theories  concerning  shock,  according 
to  Crile,1  reads  as  follows : 

"John  Hunter,  in  1784,  was  probably  the  first  to  describe  shock. 

"William  Clowes,  in  1568,  Wieseman,  in  1719,  and  Garengeot,  in 
1723,  recognized  shock,  and  attributed  it  to  the  presence  of  some 
foreign  body  in  the  wound  or  in  the  blood. 

"Guthrie,  in  his  work  'On  Gunshot  Wounds,'  speaks  of  waiting 
'until  the  alarm  and  shock  have  subsided,'  and  details  a  number  of 
cases. 

"James  Little,  in  1795,  was  the  first  writer  to  use  the  word  shock 
in  the  sense  it  is  now  employed. 

"Travers,  in  1827,  described  a  number  of  cases  of  shock,  and  be- 
lieved that  shock  to  the  nervous  system  might  cause  death  without 
reaction. 

"J.  A.  Delcasse,  in  1834,  stated  that  the  effects  of  violence  were 
transmitted  chiefly  through  the  osseous  system,  whereby  the  living 
molecules  were  separated  from  each  other,  especially  in  the  brain, 
spinal  cord,  and  liver. 

"Erichsen,  in  his  treatise  in  1864,  considered  shock  in  railroad 
and  other  accidents  to  be  due  to  the  'sharp  vibration  that  is  trans- 
mitted through  everything,' — the  immediate  lesion  being,  probably, 
of  a  molecular  character." 

We  were  brought  nearer  to  the  modern  conception  in  1870.  "In 
1870,  Goltz  made  his  classical  experiments  on  the  frog  and  concluded 
that  the  shock  phenomena  observed  were  due  to  the  vasomotor  paral- 
ysis caused  by  mechanical  violence. 

"In  1873,  Lauder  Brunton  wrote  a  monograph  on  the  subject,  in 
which  Goltz 's  theory  was  accepted.  Hofmeister,  in  1885,  wrote  that 
malnutrition  of  the  heart,  fatty  degeneration,  general  weakness,  and 
loss  of  blood  were  the  chief  factors  concerned  in  the  production  of 
shock.  Gross  describes  it  as  a  depression  of  vital  powers,  suddenly 
induced  by  external  injuries,  and  essentially  dependent  upon  a  loss 
of  innervation. 

"Agnew  wrote  that  it  is  evident,  from  a  clinical  standpoint,  that 
the  determining  causes  of  shock  must  reach  that  portion  of  the  nerv- 

91 


92  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

ous  system  from  which  the  heart  and  lungs  receive  their  motor  en- 
dowments, for  the  feeble  action  of  these  organs  is  one  of  the  fit 
observed  phenomena  of  shock."     This  last  quotation  from  his  book 
brings  us  close  to  Crile's  own  vasomotor  theory. 

A  host  of  other  writers  have  considered  the  subject  in  different 
ways  and  from  different  angles,  there  being  up  to  the  present  time, 
no  unanimity  of  opinion  as  to  its  exact  mechanism.  Perhaps  the  best 
summary  of  the  subject  which  has  appeared  to  date  is  a  critical 
abstract  by  M.  G.  Seelig,2  of  St.  Louis,  on  "The  Nature  of  Shock." 
I  shall  proceed  to  quote  very  liberally  from  it,  feeling  that  this  au- 
thor's experimental  work  and  exhaustive  literature  study  enable  him 
to  produce  an  authoritative  summary  of  the  subject. 

"For  nearly  a  century  investigators  and  clinicians  have  been  pro- 
pounding theories  and  promulgating  doctrines  that  definitely  located 
the  cause  of  shock  in  an  aberration  now  of  this  function  or  organ, 
now  of  that.  Without  exception  none  of  these  various  theories  has 
stood  the  tests  of  searching  criticism.  It  is  rational  to  hope,  there- 
fore, that  by  passing  the  various  older  working  hypotheses  in  review. 
Ave  may  at  least  partially  comprehend  why  they  have  failed,  and 
likewise  orient  ourselves  in  a  suitable  critical  attitude  regarding  the 
strength  and  weakness  of  the  new  theory. 

"How  may  we  explain  this  constant  change  of  front?  On  two 
grounds:  In  the  first  place  a  failure  to  recognize  what  was  so  clear 
to  the  elder  Gross,  namely,  that  "shock  is  a  rude  unhinging  of  the 
entire  machinery  of  life."  and  that  we  must  therefore  proceed  cau- 
tiously in  attempting  to  locate  the  unhinging  at  the  door  of  any  one 
particular  organ  or  function.  Secondly,  we  find  an  explanation  for 
the  multiplicity  of  theories  in  the  frequent  misinterpretations  of  ex- 
perimental data  or  in  the  drawing  of  unwarranted  conclusions  from 
properly  collected  data.  For  example,  to  take  up  the  most  common 
type  of  confirmed  faulty  reasoning,  almost  every  investigator  of  shock 
develops  his  line  of  thought  around  the  central  point  that  low  blood 
pressure  signifies  shock.  And  so  indeed  it  does,  but  it  has  never 
been  proved  and  should  never  be  assumed  that  low  Mood  pressure 
is  the  primary  causative  agency  of  shock." 

"The  needs  of  more  specific  criticism  make  it  imperative  to  deal 
critically  with  the  development  of  the  more  commonly  accepted  theo- 
ries of  shock,  as  we  know  them  today.  In  order  to  do  this  we  shall 
select  for  analysis  the  following  prevalent  doctrines  regarding  the 
causative  factor  in  shock,  which  is  stated  variously  to  be: 

"1.  Vasomotor  exhaustion  and  paralysis. 

"2.  Cardiac  spasm  and  eventual  failure. 


SHOCK  93 

"3.  Inhibition  of  the  functions  of  all  the  organs. 
"4.  Deficiency  of  carbon  dioxide  in  the  blood   (acapnia). 
"5.  Morphologic   changes   and   eventual  partial   or   complete   dis- 
integration of  the  ganglion  cells. 

"The  theory  of  vasomotor  exhaustion  as  the  essential  cause  of 
shock  was  established  on  what  seemed  at  the  time  to  be  a  firm  basis 
by  Crile.  His  argument  is  based  on  the  facts  that  the  essential  phe- 
nomenon of  shock  is  low  blood  pressure,  and  that  since  there  is  no 
demonstrable  lesion  in  fatal  cases,  and  no  later  effects  in  those  that 
recover,  we  must  assume  exhaustion  rather  than  structural  lesions 
to  be  the  cause  of  this  fall. 

"The  vasomotor  exhaustion  theory  has  also  been  attacked  directly 
by  the  physiologists,  Porter,  Henderson,  and  Lyon,  and  indirectly 
by  numerous  other  investigators  who  bring  forward  theories  of  their 
own — Vale,  Kinnaman,  Schur,  Weisel,  Bainbridge,  and  Parkinson. 

"Henderson  believes  that  in  shock  'the  vasomotor  center  does  its 
full  duty  almost  to  the  last,'  that  failure  of  the  circulation  is  due  to 
the  diminution  of  the  volume  of  the  blood,  by  transudation  of  its 
fluid  out  of  the  vessels  into  the  tissues,  and  that  there  is  no  'fatigue 
or  inhibition  or  failure  of  any  sort  in  the  vasomotor  center.' 

"Seelig  and  Lyon,  in  two  papers,  contest  the  validity  of  the  doc- 
trine of  exhaustion  of  the  vasomotor  centers.  In  their  first  paper 
they  measured  the  outflow  of  blood  from  the  femoral  vein  in  a  nor- 
mal dog,  before  and  after  section  of  the  sciatic  nerve.  After  sec- 
tion of  the  nerve  the  outflow  was  more  rapid,  as  was  to  be  expected. 
This  same  experiment  was  performed  on  a  dog  in  shock,  and  despite 
the  shock  the  outflow  was  more  rapid  after  section  of  the  sciatic, 
even  more  rapid,  proportionally,  than  in  the  normal  dog,  thus  dem- 
onstrating that  the  vasomotor  center  was  transmitting  active  tonic 
impulses  through  the  sciatic,  even  in  a  state  of  profound  shock. 
Moreover,  by  ophthalmoscopic  examinations  they  determined  that 
the  arteries  of  the  retina  not  only  did  not  dilate,  but  rather  that 
they  actively  contracted  as  the  animal  went  into  shock.  As  joint 
author  in  this  work,  it  is  only  fair  for  me  (Seelig)  to  state  that 
Erlanger  contests  our  reasoning  as  regards  rate  of  outflow,  and  also 
that  we  should  have  proved,  but  did  not,  that  the  contraction  of  the 
retinal  vessels  is  really  an  active,  tonic  contraction  and  not  a  pas- 
sive one  due  to  empty  vessels.  In  a  second  paper,  Seelig  and 
Lyon  attack  the  problem  from  a  different  point  of  view.  They  em- 
phasize the  fact  that  in  normal  animals  stimulation  of  the  central 
end  of  the  cut  vagus  causes  a  rise  of  blood  pressure,  and  that  this 
rise  occurs  even  when  the  animals  are  in  the  profoundest  degree  of 


94  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

shock.  Furthermore,  utilizing  Porter's  doctrine  of  percentage  rise, 
they  found  that  the  rise  was  proportionally  as  high  in  profound 
shock  as  in  the  normal  animal.  In  order  to  exclude  all  reflex  effects 
on  the  heart,  they  cut  both  vagi  and  removed  the  right  and  left 
stellate  ganglia;  but  even  after  these  procedures,  stimulation  of  the 
central  end  of  the  vagus  was  followed  by  a  rise  in  pressure.  These 
authors  conclude  from  their  experiments  that  the  vasomotor  centers 
are  active  in  shock. 

' '  Of  these  theories  which  account  for  the  mechanism  of  shock,  none 
has  made  a  stronger  appeal  to  the  clinician  than  the  doctrine  that 
cardiac  failure  is  the  essential  element  in  the  obscure  symptom- 
complex — a  principle  laid  down  most  emphatically  by  Boise,  al- 
though Howell  also  admits  cardiac  shock,  as  well  as  vascular 
shock.  Boise,  who  bases  his  views  largely  on  the  experiments  of 
Crile,  Howell,  and  Porter,  attempts  to  prove  that  as  a  result  of  ex- 
cessive stimulation  of  the  augmentor  nerves  of  the  heart  (due  to 
peripheral  trauma)  this  organ  is  thrown  into  spasm  ;  that,  therefore, 
in  shock  there  is  increased  systole,  decreased  diastole,  lessened  output 
of  blood  from  the  heart,  and  therefore  low  blood  pressure.  The  low- 
ered blood  pressure  in  its  turn  leads  to  further  decrease  in  the  output, 
establishing,  as  it  were,  a  vicious  circle. 

"The  heart  is  compromised  in  shock,  beyond  a  doubt,  but  cardiac 
inefficiency  is  certainly  not  the  primary  cause  of  shock. 

"Meltzer,  it  was,  who  developed  in  his  characteristically  lucid 
fashion  the  doctrine  of  inhibition  of  functions  as  the  underlying  es- 
sential phenomenon  in  shock. 

"Meltzer  ventures  the  assumption  that  the  'various  injuries  which 
are  capable  of  bringing  on  shock,  do  so  by  favoring  the  development 
of  the  inhibitory  side  of  all  the  functions  of  the  body. '  This  predomi- 
nance of  inhibition  makes  its  appearance  at  first  in  those  functions 
which  are  of  less  immediate  importance  to  lite,  and  are  therefore, 
less  insured  by  safeguards  protecting  their  equilibrium.  With  in- 
creased injury,  the  inhibition  also  spreads  to  the  more  vital  and  bet- 
ter protected  functions  of  the  nervous  system. 

"Such  a  doctrine  as  this  serves  well  as  a  physiological  hypothesis, 
but  to  the  clinical  mind  searching  for  light  it  is  not  very  satisfying. 

"The  doctrine  of  acapnia,  viz.,  that  shock  is  due  to  a  deficiency  of 
carbon  dioxide  in  the  blood,  was  enunciated  by  Henderson  within 
the  past  decade,  and  for  a  time  stimulated  much  work  and  much  criti- 
cism. Henderson  argues  that  the  traumata  that  induce  shock  cause 
rapid  deep  breathing  (hyperpnea)  as  the  result  of  pain  or  excite- 
ment.    This  rapid  dee))  breathing  in  its  turn  causes  an  undue  ventila- 


SHOCK  95 

tion  of  the  lungs,  during  which  ventilation,  carbon  dioxide  is  rapidly 
swept  out  of  the  circulation.  Furthermore,  when  viscera  are  ex- 
posed, in  an  ordinary  laparotomy,  carbon  dioxide  is  exhaled  from 
their  surfaces,  thus  lessening  the  quantity  of  this  gas  in  the  blood. 
By  blood  gas  analyses,  Henderson  claims  to  have  proved  this  primary 
contention  beyond  a  doubt.  Now  carbon  dioxide  is  not,  as  it  is  so 
commonly  regarded,  merely  a  poisonous  excretion. 

"When  there  is  a  reduction  of  carbon  dioxide  in  the  blood,  the 
walls  of  the  veins  relax,  the  pressure  in  them  falls,  blood  accumu- 
lates in  them,  and  only  a  small  amount  is  transmitted  to  the  heart. 
Constriction  of  the  arteries  may  for  a  time  maintain  a  fair  blood 
pressure.  At  last  the  supply  reaching  the  right  auricles  becomes 
so  reduced  that  arterial  pressure  falls,  the  heart  beat  becomes  quick, 
the  output  is  small,  and  severe  shock  is  established.  Deficiency  of 
carbon  dioxide  has  another  remarkable  effect.  When  the  deviation 
from  normal  is  considerable  there  is  a  tendency  for  fluid  to  exude 
from  the  plasma  into  the  tissues.  The  plasma  therefore  becomes  con- 
centrated and  the  total  volume  of  blood  diminished. 

"The  conclusion  that  acapnia  does  not  suffice  as  a  cause  of  shock 
therefore  seems  to  be  inevitable,  even  despite  the  large  quantity  of 
data  so  carefully  collected  by  Henderson  over  so  long  a  period  of 
time. ' ' 

In  support  of  this  negative  conclusion,  Seelig  quotes  the  work  of 
Erlanger,  Short  and  himself.  It  has  become  apparent  to  him  as  to 
practically  every  other  clinician  interested  in  this  subject,  that  our 
every-day  observations  in  practical  life  make  it  seem  unlikely. 

In  reviewing  the  ' '  exhaustion  hypothesis, ' '  Seelig  writes :  ' '  This 
hypothesis  assumes  'that  animals  that  are  especially  capable  of  being 
shocked  are  those  whose  self-preservation  is  dependent  upon  special 
forms  of  motor  activity;  that  motor  activity  is  excited  by  adequate 
stimuli,  through  nerve  tissue  directly.  Whatever  may  have  been  the 
origin  of  the  motor  mechanism  and  its  adaptive  response  on  stimu- 
lation, there  is  in  each  individual,  at  a  given  time,  a  limited  amount 
of  potential  energy ;  that  motor  activity  following  each  adequate  stim- 
ulus diminishes  the  amount  of  this  potential  energy;  that  in  any 
animal,  a  sufficient  number  and  intensity  of  the  stimuli  leads  in- 
evitably to  exhaustion  or  death ;  that  when  the  motor  activity  takes 
the  form  of  obvious  work  performed,  such  as  running,  the  phe- 
nomenon expressing  the  depletion  of  the  vital  force  is  termed  phys- 
ical exhaustion ;  and  that  when  the  expenditure  of  the  vital  force 
is  due  to  stimuli  which  lead  to  no  obvious  work  performed,  especially 


96  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

if  the  stimuli  are  strong  and  the  expenditure  of  energy  rapid,  it 
is  designated  as  shock. 

"The  essence  of  the  doctrine  lies  in  the  belief  that  the  brain  cells 
are  composed  of  labile  compounds  capable,  when  adequately  stimu- 
lated, of  converting  their  potential  energy  into  kinetic.  If  this 
power  to  convert  is  unduly  excited  and  the  cells  immediately  fixed, 
stained,  and  studied  microscopically,  they  show  what  seems  to  be 
a  deep  overstaining  due  to  an  overproduction  of  Nissl  substance.  If 
the  excitation  is  continued,  the  cells  stain  much  lighter  and  show  an 
altered  relation  between  cytoplasm  and  nucleus,  as  well  as  altered 
form;  finally,  if  the  excitation  is  continued  further,  the  cells  take 
practically  no  stain  (loss  of  Nissl  substance)  and  are  altered  in  form 
up  to  the  point  of  actual  disruption  (Crile). 

"In  order  to  controvert  this  conclusion,  it  is  necessary  to  contro- 
vert his  facts  or  to  show  faulty  logic  in  his  process  of  deduction.  The 
facts  as  they  stand  arc  merely  confirmations  of  similar  facts  made 
by  such  trustworthy  workers  as  Hodge,  Hertwig  and  his  school,  and 
Dolley.     No  one  has  brought  forward  concrete  data  in  rebuttal. 

'"•'rile  is  concentrated  on  demonstrating  a  practical  method;  and 
in  his  very  attempl  he  seems  to  miss  the  point  that  hs  aims  for.  He 
admits,  without  so  stating  specifically,  the  qualitative  similarity  and 
quantitative  differences  of  all  afferent  stimuli.  lie  demonstrated 
that  fear,  trauma,  activity,  senility,  and  numerous  other  states  in- 
duce brain  cell  changes  exactly  similar  to  those  of  shock. 

"He  thereby  links  shock  with  a  conglomerate  group  of  other  en- 
tities all  the  while  that  he  is  striving  to  isolate  it.  Possibly  the 
statement  that  he  desires  to  isolate  shock  as  an  entity  is  a  misstate- 
ment, but  Crile's  whole  line  of  thought  and  his  general  conclusions 
warrant  the  belief  that  he  is  striving  to  determine  the  etiologic 
factor  underlying  shock  as  a  definite  symptom-complex. 

"Crile  may  encounter  no  difficulty  in  showing  that  the  condition 
of  shock  has  a  definite  morphological  representation  in  the  ganglion 
cells  of  the  cerebellum,  but  he  frequently  approaches  dangerously 
near  the  border  line  of  speculative  metaphysical  reasoning  in  his  at- 
tempts to  prove  that  the>e  same  morphological  changes  are  the  prime 
cause  of  shock.     And  thus  the  problem  stands — still  unsolved." 

It  is  suggested  that  those  (specially  interested  in  the  study  of  the 
mechanism  of  shock,  read  Seelig's  exhaustive  and  thoughtful  collec- 
tive abstract  in  its  entirety,  the  foregoing  being  made  up  simply  of 
ex1  racts  from  it. 

The  uncertainty  which  surrounds  the  subject  comes  out  still  more 
clearly  the  farther  one  goes  into  the  literature.     As  an  example  of 


SHOCK  97 

this  statement,  read  what  no  less  an  authority  than  Henderson3  has 
recently  promulgated. 

"Shock,  in  the  broad  sense  in  which  the  term  is  often  used,  is  not 
a  single,  clear-cut  disorder,  but  a  group  of  conditions  which  differ 
one  from  another  fundamentally.  However,  owing  to  the  fact  that 
these  various  conditions  resemble  one  another  superficially,  they  are 
generally  confused.  The  first  problem  is  to  define  and  distinguish  each 
one." 

Feeling  that  "shock"  was  too  broad  a  term  and  that  one  might 
more  clearly  define  his  meaning  in  terms  of  blood  pressure,  Bartlett4 
endeavored  at  Erlanger's  suggestion  to  ascertain  by  a  direct  method 
whether  vasodilatation  or  vasoconstriction  characterizes  low  blood 
pressure  produced  in  the  dog  by  trauma.  To  this  end,  salt  solution 
under  constant  pressure  was  injected  into  medium  sized  arteries  and 
the  rate  of  inflow  studied  as  the  blood  pressure  fell  in  consequence 
of  injury  to  the  cerebrum,  the  extremities,  and  the  abdominal 
viscera.  After  the  first  set  of  observations,  the  trauma  was  applied 
more  or  less  continuously  to  the  end  of  each  experiment. 

In  some  of  these  experiments,  the  femoral  artery  was  selected, 
It  was  divided  high  and  a  cannula  was  placed  in  the  distal  end.  In 
other  experiments,  the  splenic  artery  was  divided  as  near  the  aorta 
as  possible,  a  cannula  was  inserted  clistally,  and  all  the  branches 
supplying  the  spleen  were  ligated,  leaving  only  the  large  terminal 
branch  which  anastomoses  with  the  coronary  artery  of  the  greater 
curvature. 

As  a  result  of  this  experimental  work  on  ten  animals,  there  can 
be  no  doubt  of  the  fact  that  the  rate  of  inflow  in  shock  was  faster 
than  normally  the  case,  the  average  increase  being  36  per  cent.  It 
is  concluded,  therefore,  that  decreased  vasomotor  tone  is  an  accom- 
paniment of  shock. 

It  occurred  to  Mann5  that  the  study  of  shock  was  important,  since, 
despite  the  enormous  amount  of  work  done  on  this  subject,  a  critical 
review  of  the  literature  showed  an  astounding  amount  of  contradictory 
experimental  data  and  a  great  number  of  diverse  conclusions  based 
thereon.  He  feels  that  the  use  of  the  word  "shock"  should  be 
avoided,  and  instead,  an  accurate  and  detailed  description  of  the  pa- 
tient's condition  should  be  given.  If  the  term  be  used  at  all,  it  should 
be  applied  to  the  condition  in  which,  without  any  grossly  discerni- 
ble hemorrhage  having  occurred,  the  amount  of  circulatory  fluid  is 
greatly  diminished  on  account  of  the  stagnation  of  the  blood  in  the 
smaller  veins  and  capillaries,  or  by  exudation  of  the  fluid  and  cellu- 
lar elements  of  the  blood  from  the  same. 


98  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

Engstacl6  believes  that  psychic  and  physical  shock  are  correlated: 
that  psychic  shock  may  follow  a  very  minor  or  major  operation,  be 
transitory  in  effect,  or  remain  permanent  and  wreck  the  patient's 
life. 

The  various  observations  regarding  the  treatment  of  shock  have 
been  almost  as  divergent  as  the  theories  which  were  advanced  to  ex- 
plain the  causes  and  mechanism  of  it.  ('rile7  states  that  ''nitro- 
glycerin, atropine,  saline  infusion,  digitalis,  alcohol,  caffeine,  cam- 
phor, ergotin.  ether,  strophanthus,  etc.,  have  so  many  individual,  even 
contradictory,  actions  that  it  would  seem  that  these  drugs  could  not 
all  be  indicated  in  the  same  condition.  In  selecting  one  of  these 
drugs  in  a  case  of  shock  or  collapse,  would  it  net  first  be  necessary  to 
know  definitely  to  what  the  fall  in  the  blood  pressure  is  due?  It  is 
due  to  the  exhaustion  of  the  anatomic  periphery  (blood  vessels)  ; 
of  the  heart;  of  the  vasomotor;  of  the  cardiac  center:  or  of  the  re- 
spiratory center;  is  it  an  exhaustion  or  a  suspension  of  function,  or 
has  the  blood  plasma  passed  through  the  vessel  walls?  If  it  is  din 
to  exhaustion  of  one  or  more  of  these  centers  or  organs,  would  stimu- 
lation relieve  the  exhaustion,  or  would  an  increased  exhaustion  fol- 
low the  stimulation.'  Would  it  b<  better  t<>  lash  the  tired  horse  or 
givi   it  restf 

"If  not  all  the  centers  and  organs  are  exhausted,  would  it  be  ad- 
vantageous to  stimulate  those  not  affected  while  the  exhausted  ones' 
rested.'  Would  it  be  advantageous  to  restore  the  blood  pressure,  as 
far  as  possible,  by  use  of  harmless  mechanical  mean-.' 

"Are  not  the  centers  governing  the  circulation  automatic,  and  are 
they  not  all  automatically  stimulated?  And  are  they  not  all  stimu- 
lated to  tlie  point  of  exhaustion  before  the  final  circulatory  break-down 
occurs.'  As  applied  to  the  centers  that  are  depressed,  is  it  better  to 
depend  upon  a  drug  stimulation,  or  upon  automatic  stimulation?" 

"Whatever  one  may  think  of  (file's  explanation  of  the  phenomena 
of  shock,  one  can  not  fail  to  agree  with  the  underlying  principles  of 
treatment  as  advanced  by  this  gifted  research  worker  and  surgeon. 

Shock  may  at  times  lie  anticipated  and  prevented  by  far-reaching 
and  rational  preoperative  consideration  of  an  individual  patient's 
needs.  It  is  often  possible  to  improve  a  bad  risk,  merely  by  rest  in 
bed  and  proper  feeding,   previous  to  the  operation. 

The  condition  of  many  a  dehydrated  person  can  be  marvelously 
improved  by  the  introduction  of  liberal  amounts  of  water  under  the 
skin  or  into  the  rectum.  Of  course,  no  preliminary  catharsis  should 
be  indulged,  in  here. 


SHOCK  99 

It  is  an  obvious  though  much  neglected  fact  that  a  long  and  te- 
dious cross-country  or  railway  journey  renders  an  already  sick  in- 
dividual doubly  unfit  to  bear  the  strain  of  a  major  surgical  proce- 
dure before  adequate  time  for  rest  has  been  allowed. 

A  preliminary  blood  transfusion,  unless  there  be  active  hemorrhage 
from  a  vessel  that  can  not  be  controlled,  will  accomplish  wonders 
toward  improving  a  patient's  condition  for  operation  and  now  that 
the  procedure  has  become  so  common  and  the  technic  been  so  greatly 
simplified,  one  is  surprised  that  it  is  not  more  often  resorted  to  as  a 
preoperative  measure.  (As  early  as  1905  Crile  was  experimenting 
along  this  line.) 

The  surgeon  must  individualize  in  many  directions ;  for  instance 
it  is  obviously  unfair  to  the  chronic  alcoholic  to  send  him  to  the  oper- 
ating table  after  having  been  deprived  for  several  days  of  his  cus- 
tomary stimulant.  The  same  may  safely  be  said  of  the  morphine 
and  other  drug  habitues. 

A  night 's  sleep  must  be  assured  to  every  patient  who  is  going  to  be 
operated  on  the  following  morning.  As  a  matter  of  course,  mor- 
phine is  our  most  reliable  agent  for  this  purpose.  Should  there, 
however,  be  contraindications  to  its  use,  an  excellent  substitute  will 
be  found  in  the  rectal  administration  of  potassium  bromide  (2 
drams)  and  chloral  hydrate  (10  drams)  in  8  ounces  of  water. 

Prophylaxis  on  the  operating  table  concerns  itself  first  of  all  with 
body  warmth.  It  is  taken  for  granted  that  the  temperature  of  the 
room  should  be  about  80°  F.  Crile  (personal  demonstration)  for- 
merly used  an  operating  table  which  was  heated  by  water  circula- 
tion, while  Robb  (personal  demonstration)  employed  a  much  sim- 
pler and  equally  effective  plan  of  accomplishing  the  same  object ;  viz., 
he  had  a  number  of  ordinary  incandescent  bulbs  attached  under- 
neath the  top  of  the  table  and  turned  them  on  or  off  at  will. 

Hemorrhage  and  shock  have  distinctly  different  physiologic  effects 
although  their  clinical  effects  are  often  by  no  means  easy  to  dis- 
tinguish and  may,  of  course,  be  mixed  in  the  same  individual.  How- 
ever this  may  be,  it  will  be  readily  granted  that  accurate  hemostasis, 
inasmuch  as  it  tends  to  keep  the  patient  in  good  condition,  is  in  a 
way  a  preventive  of  shock. 

While  not  an  advocate  of  haste  in  operating,  I  still  believe  all  ob- 
servers will  admit  that  the  man  who  takes  all  of  the  patient's  needs 
into  consideration  and  gets  through  an  operation  quickly  will,  other 
things  being  equal,  observe  less  shock  in  his  clinic  than  will  the  man 
whose  work  entails  long  exposure.     Still  more  important,  perhaps, 


100  AFTER-TREATMENT    OP    SURGICAL   PATIENTS 

in  this  connection,  are  delicate  manipulation,  gentle  retraction,  and 
the  "featheredged"  dissection  of  ('rile. 

Nerve-blocking,  even  where  general  anesthesia  is  used,  is  un- 
doubtedly one  of  the  best  methods  of  shock  prevention  at  our  com- 
mand. One  of  the  authors  observed  an  intrascapulothoracic  ampu- 
tation done  without  blocking  of  the  brachial  plexus,  by  one  of  the 
most  distinguished  operators  in  America,  with  the  result  that  the 
patient,  apparently  of  a  strong  constitution,  died  the  following  night. 
A  few  weeks  later,  he  witnessed  a  much  less  expert  surgeon  at  his 
first  attempt  of  this  kind;  but  the  brachial  plexus  had  been  blocked 
with  cocaine  and  practically  no  shock  at  all  followed. 

Cushing  long  ago  called  our  attention  to  the  fact  that  the  condi- 
tion of  shock  persists  as  long  as  centrifugal,  depressing  influences 
are  given  off  from  a  crushed  and  mangled  extremity,  the  result  01 
railway  or  other  similar  accident.  He  very  rightly  urges,  therefore, 
the  earliest  and  gentlest  possible  amputation  as  the  most  logical 
means  of  combating  shock. 

When  a  patient  has  returned  from  the  operating  room  in  shock, 
the  first  thing  to  be  considered  is  the  conservation  of  the  external 
body  heat,  since  cold  extremities,  one  of  the  earliest  manifestations 
of  shock,  indicate  a  derangement  of  the  cerebral  centers  which  pre- 
side over  the  distribution  of  heat.  The  use  of  blankets,  electric 
warming  pads,  or  the  electric  light  cage  are  among  the  readiest 
means  at  our  command  for  combating  chilling  surfaces.  If  the 
patient  is  conscious,  hot  stimulating  drinks,  such  as  tea,  coffee,  and 
soup  should  be  administered  often  and  in  small  quantities. 

Opinions  are  divided  as  to  the  value  of  alcohol  in  this  connect  inn. 
The  animal  experiment  of  ('rile  would  tend  to  show  that  the  lowered 
blood  pressure,  characteristic  of  this  condition,  is  by  no  means 
helped  by  alcohol,  but  is  probably  influenced  in  the  opposite  direc- 
tion. 

In  shock,  there  is  every  evidence  that  arterial  blood  accumu- 
lates unduly  in  the  large  internal  veins,  leaving  a  deficient  supply 
for  the  cerebral  centers,  and  Tor  the  heart  to  contract  upon,  hence 
it  would  occur  at  once  even  to  a  beginner  to  lower  the  head  (Fig. 
20)  and  elevate  the  foot  of  the  bed.  Another  move  in  the  same  direc- 
tion is  to  bandage  the  extremities  and  put  gentle  compression  on  the 
abdomen,  thereby  aiding  the  return  How  of  blood  out  of  the  large 
veins  into  the  arterial  side  of  the  circulatory  system  and  helping 
to  reestablish  the  disturbed  balance  in  the  blood  pressure. 

We  have  at  our  command,  two  drugs  which  act  upon  the  muscu- 
lature of  the  peripheral   arterial   vessels  and  thus  aid   in  restoring 


SHOCK 


101 


blood  pressure.  They  are  adrenalin  and  pituitrin.  The  action  of  the 
former  is  exceedingly  transient  and  should  be  thrown  directly  into 
a  vein  in  order  that  the  maximum  efficiency  of  it  may  be  realized. 
About  10  minims  of  a  1 :1000  solution  are  best  injected  in  the  follow- 
ing manner :  the  needle  of  a  hypodermic  syringe  filled  with  adren- 
alin solution  is  thrust  into  the  lumen  of  a  rubber  tube  which  is  carry- 
ing salt  solution  into  a  vein  and  thus,  in  a  very  simple  manner,  the 
drug  in  dilute  form  is  carried  into  the  circulatory  system  and  rapidly 
diffused.  Since  the  effect  is  so  transient,  the  close  must  be  repeated 
every  few  minutes  until  a  physiologic  effect  is  apparent,  though 
the  systolic  pressure  must  not  go  over  100  says  Corbett.     Pituitrin 


Fig.    20.— The   patient's    head    is    lowered   in    order    that    blood    mav    gravitate    to    the    cerebral 
centers  and  the  heart.     Water  is  given  continuously  under  the  skin  and  into   the   rectum. 

is  thought  by  many  to  have  a  more  sustained  and  perhaps  a  generally 
more  satisfactory  action.  It  is  given  by  intramuscular  injection. 
Each  original  package  as  put  out  by  the  manufacturer,  contains  one 
to  two  doses. 

Subcutaneous  injection  of  salt  solution  or,  as  I  think  better,  of 
sterile  water,  is  generally  advocated  in  these  cases,  although  it  is 
hardly  reasonable  to  consider  this  one  of  the  most  important  factors 
in  treatment. 

Crile  informs  me  in  a  recent  personal  communication  that  he  con- 


102  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

siders  blood  transfusion  the  best  remedy  which  we  possess  for  shock. 
While  this  position  lias  as  yet  not  been  generally  accepted,  still  we 
can  not  lightly  pass  over  any  contribution  to  the  surgery  of  the 
vascular  system  which  emanates  from  this  source  of  so  much  ex- 
perimental, as  well  as  clinical,  knowledge. 

The  general  rules  for  the  use  of  sedatives  apply  here  as  well  as 
elsewhere.  They  are  of  undoubted  value  only  inasmuch  as  they  inter- 
fere with  the  perception  of  the  various  stimuli  which  may,  in  the 
aggregate,  add  to  the  general  state  of  depression. 

Bibliography 

iCrile,  George  W.:  An  Experimental  Research  into  Surgical  Shock,  J.  B.  Lip- 
pineott  Co.,  Philadelphia. 

-Si'dig,  M.  G.:     Collective  Abstract  on  Shock,  Internal  Abstr.  Surg.,  1914. 

"Henderson,  Y. :  The  Pathology  of  Shock,  Tr.  Internal  Cong.  Med..,  London, 
August,  1913,  Surg.,  Gynec.  and  Obst. 

iBartlett,  Willard:  An  Experimental  Study  of  the  Arteries  in  Shock,  Jour. 
Exper.   .Med..    1912,  xv,  No.  4. 

'Mann,  F.  C. :  The  Peripheral  Origin  of  Surgical  Shock,  Bull.  Johns  Hop- 
kins Hosp.,  1914,  x.w. 

eEngstad,  .1.  E.:  Psychic  Shock  Following  Operations,  Journal  Lancet,  1914, 
xxxiv,  5-16. 

"Crilo,  George  \V. :  Blood  Pressure  in  Surgery,  J.  B.  Lippineott  Co.,  Phila- 
delphia and  London,  190.",. 


CHAPTER  XIII 

HEMORRHAGE 
By  Willard  Bartlett,  St.  Louis,  Mo. 

Postoperative  hemorrhage  is  one  of  the  most  distressing  accidents 
that  may  complicate  the  after-treatment  of  a  surgical  patient.  This 
is  particularly  true,  if  it  be  the  result  of  an  oversight  or  neglect  on 
the  operator's  part,  and  the  rapidity  with  which  it  sometimes  over- 
whelms the  unhappy  patient,  leaves  no  time  for  remedial  measures. 

Hemorrhage  may  be  defined  in  a  number  of  ways ;  viz.,  Concealed, 
Open,  and  Mixed.  The  first  two  are  self-explanatory,  while  by 
"Mixed  Hemorrhage,"  is  meant  that  variety  in  which  the  bleeding 
is  primarily  within  a  body  cavity  or  wound  defect,  and  approaches 
the  open  type  when  the  blood  follows  a  drain  or  tampon  to  the  sur- 
face. Hemorrhage  may,  of  course,  be  arterial,  venous  or  capillary, 
if  one  has  the  source  of  it  in  mind  when  the  definition  is  formulated, 
and  when  classifying  according  to  its  causation,  it  may  be  due  to 
surgical  trauma,  pressure  decubitus,  to  ercsions  of  various  sorts,  to 
the  progress  of  a  dyscrasia,  changing  the  blood  itself,  or  to  a  general- 
pathologic  process  affecting  the  vessel  walls.  Perhaps  the  most  gen- 
erally useful  classification  of  hemorrhage,  from  the  viewpoint  of  the 
operator,  is  one  which  takes  into  consideration  the  time  of  onset, 
hence  arise  the  terms  Primary,  Reactionary,  (Matas1),  and  Second- 
ary. 

Primary  liemorrliage,  as  the  name  indicates,  begins  at  the  time  of 
operation  and  continues  after  the  patient  is  put  to  bed.  A  striking 
example  of  it  is  seen  in  the  recital  of  the  following  case  which  came 
under  my  observation:  An  attempt  was  made  to  ligate  the  innomi- 
nate artery  for  aneurysm  of  that  vessel.  The  surgeon  had  just 
sawed  through  the  clavicle  and  was  trying  to  elevate  it,  when  a  tor- 
rent of  blood  gushed  out.  An  effort  to  control  the  hemorrhage  was 
made  with  gauze  packs  and  pressure,  but  the  loss  continued  during 
the  thirty  minutes  that  the  patient  lived  after  the  accident.  The 
clavicle  was  found,  at  autopsy,  to  have  formed  a  portion  of  the 
wall  of  the  aneurysm,  and  to  have  been  considerably  eroded.  This 
is  an  example,  not  only  of  primary,  but  also  of  external,  arterial, 
and  pathologic  hemorrhage,  as  well.  From  this  it  may  be  seen  that  no 
one  classification  serves  to  completely  define  the  type  of  hemorrhage 
in  many  instances. 

103 


104  AFTER-TPFATMENT   OF    SURGICAL   PATIENTS 

A  very  well-known  type  of  primary  hemorrhage  is  seen  after  the 
division  of  kidney  parenchyma  for  any  purpose  which  entails  oper- 
ating on  the  pelvis.  No  matter  how  accurately  the  defect  is  sutured, 
blood  almost  invariably  finds  its  way  down  the  ureter,  and  as  it 
passes  in  the  form  of  a  clot,  characteristic  colic  is  experienced. 

A  form  of  primary  hemorrhage,  pathologic  in  nature,  was  seen 
by  us  a  few  years  ago  when  an  operator  made  an  extensive  incision 
into  a  myelogenic  carcinoma  situated  in  the  upper  end  of  the  hu- 
merus. He  was  unable  to  control  the  bleeding  which  continued  for 
days,  and  until  the  patient  was  exsanguinated. 

I  know  of  another  instance  in  which  a  crucial  incision  was  made 
through  an  enormous  carbuncle  and  well  into  the  surrounding  edem- 
atous tissues  of  the  neck.  The  patient  never  ceased  to  bleed  until 
his  death  some  twenty  hours  later.  This  was  another  form  of  patho- 
logic primary  hemorrhage. 

A  primary  hemorrhage  of  the  type  due  to  dyserasia  was  seen  after 
a  common  duct  operation  on  a  highly  jaundiced  patient.  Every 
stitch  hole,  as  well  as  the  incision  itself,  continued  to  ooze  from  the 
time  they  were  made  until  a  blood  transfusion  was  done. 

The  study  of  reactionary  hemorrhage  (loosely  termed  "delayed 
hemorrhage"),  is  a  source  of  the  keenest  interest  to  the  operator, 
since  this  type,  more  frequently  than  the  primary  or  secondary 
varieties,  is  directly  under  his  control  and  may,  in  many  instances,  be 
prevented  if  proper  care  and  foresight  are  exercised. 

During  the  time  that  the  patient  is  regaining  consciousness  he  fre- 
quently increases  the  blood  pressure  ;is  a  direct  result  of  restlessness, 
and  in  consequence,  forces  blood  out  of  the  tiny  vessels  which  had 
been  clamped  but  not  tied,  because  they  remained  dry  while  the  pa- 
tient was  perfectly  quiet.  Many  a  hematoma,  infected  or  otherwise, 
will  be  noted  at  the  first  dressing  by  the  operator  who  does  not  ligate 
every  vessel  during  the  early  stages  of  an  operative  procedure. 

Again  reactionary  hemorrhage,  sometimes  of  alarming  extent,  is 
the  variety  which  comes  after  the  use  of  spring  clamps  for  the  tem- 
porary control  of  the  blood  vessels  during  operations  on  the  hollow 
abdominal  viscera.  This  can  be  most  readily  proved  by  stomach  lav- 
age after  any  gastroenterostomy.  Reactionary  hemorrhage  may  be- 
come a  matter  of  the  gravest  importance  in  an  instance  like  the  fol- 
lowing one  which  I  observed:  About  two  hours  after  a  thyroidec- 
tomy, the  surgeon  was  summoned  to  the  operating  room,  to  find  his 
patient  suffocating  and  the  neck  enormously  distended.  The  stitches 
were  removed,  a  large  blood  clot  rapidly  evacuated,  and  one  of  the 
ima  vessels  from  which  a  ligature  had  slipped,  quickly  secured. 


HEMORRHAGE  105 

Secondary  hemorrhage  comes  at  a  time  remote  by  several  days  at 
least,  from  the  date  of  the  operation  and  is  common  after  the  sepa- 
ration of  a  slough  in  many  situations,  and  resulted  in  a  high  mortality 
during  Percy's  earlier  work  with  the  cautery  in  cancer  of  the  cer- 
vix. He  soon  found  it  advisable  to  ligate  both  internal  iliac  arteries 
as  a  prophylactic  measure.  This  form  of  hemorrhage,  slight  in  ex- 
tent, is  perhaps  most  commonly  seen  now  in  the  separation  of  the 
sloughs,  which  result  from  the  prevalent  use  of  the  clamp  and  cau- 
tery operations  for  hemorrhoids. 

A  secondary  hemorrhage,  as  a  result  of  erosion,  was  exceedingly 
common  in  the  preantiseptic  clays  when  hospital  gangrene  was  so 
greatly  dreaded.  The  authors  observed  a  classical  example  of  it  in 
a  patient  whose  lower  jaw  had  to  be  removed  for  carcinoma.  He 
commenced  to  bleed  almost  two  weeks  later  from  the  branches  of  the 
external  carotid  artery;  infected  material  had  found  its  way  out  of 
the  mouth  down  into  the  planes  of  the  neck,  and  erosion  of  these 
large  vessels  taken  place.  This  man's  life  was  saved  by  the  ligation 
of  his  common  carotid  artery,  a  procedure  which  we  find  has  been 
successful  in  two-thirds  of  the  cases  in  which  it  has  been  attempted. 

I  have  noted  an  instance  of  secondary  hemorrhage  from  pressure 
decubitus  of  the  iliac  vessels,  in  consequence  of  a  rubber  drain  tube 
being  improperly  placed  and  left  too  long  in  the  abdomen  after  an 
operation  for  acute  suppurative  appendicitis.  A  very  common 
pathologic  cause  of  secondary  hemorrhage  is  arteriosclerosis.  The 
early  history  of  ligation  for  aneurysm  of  large  vessels  is  replete  with 
instances  in  which  a  fatal  termination  ensued  upon  the  ligature  cut- 
ting through  rigid  vessel  walls.  Secondary  hemorrhage  was  seen 
when  a  heavy  ligature  cut  through  liver  substance  five  days  after  the 
removal  of  a  tumor  from  the  lower  border  of  that  organ.  The  pa- 
tient was  so  reduced  that  she  succumbed  later  to  the  effects  of 
anemia. 

The  amount  of  blood  in  the  human  body  has  been  variously  esti- 
mated by  early  writers  to  be  from  %0  up  to  y5  of  the  body  weight. 
Most  authors  of  recent  times,  however,  have  agreed  with  Howell2  and 
with  Stewart3  in  the  statement  that  %3  of  the  body  weight  consisted 
of  blood.  This  matter  can  hardly  be  considered  definitely  settled,  if 
one  agrees  with  Crile,4  who  writes :  "It  must  be  concluded  that  with 
our  present  knowledge  the  question  is  still  under  judgment.  The 
very  nature  of  the  problem  makes  it  a  difficult  one  to  solve,  and  at  the 
best  the  statement  that  the  ratio  between  the  total  blood  mass  and  the 
body  weight  is  a  constant  one  must  be  considered  to  be  only  very 
roughly  approximating  the  truth." 


106  AFTER-TREATMENT   OF    SURGICAL    PATIENTS 

It  would  prove  a  matter  of  vital  importance  to  the  surgeon  to 
know  just  what  percentage  of  a  patient's  blood  might  be  lost  and  the 
patient  still  survive.  Of  course,  circumstances  alter  cases;  especially 
is  this  true  regarding  rapidity  with  which  blood  is  lost,  hence,  no 
general  definite  statement  can  be  made  as  to  the  exact  amount  which 
may  be  lost  without  causing  the  death  of  the  individual.  Still,  most 
authorities  agree  with  Howell  that  3  per  cent  of  the  body  weight 
may  be  lost  in  blood  and  the  patient  recover.  Matas  states  that  the 
loss  of  one-half  the  individual's  blood  will  certainly  cause  his  death. 
A  very  illuminating  statement  along  this  line  may  lie  quoted  from 
Tillmans5  who  writes  that.  '"After  severe  loss  of  blood  every  sur- 
geon has  seen  in  a  relatively  short  time — two  to  three  days — threaten- 
ing symptoms  vanish  in  cases  where  he  expected  certain  death;  and 
again,  on  the  other  hand,  some  patients  go  into  collapse  after  the 
loss  of  very  little  blood.  Very  young  children  may  be  endangered 
by  an  insignificant  hemorrhage,  and  weakly  children  a  year  old  have 
died  after  the  loss  of  only  250  gm.  of  blood.  In  strong  adults,  who 
are  otherwise  healthy,  the  loss  of  half  the  total  amount  of  blood  is 
sure  to  be  fatal.  Women  appear  to  stand  the  loss  of  blood  better 
than  men.  The  formation  of  new  blood  seems  to  take  place  more 
easily  and  rapidly  in  them  on  account  of  the  periodic  replacement 
of  the  blood  Losl  in  every  menstruation  (Landois).  Pat  people  and 
old  and  weak  individuals  are  very  susceptible  to  the  loss  of  blood.  The 
more  rapidly  the  hemorrhage  takes  place  the  more  dangerous  it  is." 

After  performing  forty-seven  animal  experiments  for  hemorrhage 
and  operating  a  large  number  of  patients  affected  by  it.  Crile  wrote: 
"In  all  varieties  of  hemorrhage  from  normal  animals  there  is  an  im- 
mediate tendency  to  a  compensatory  or  natural  recovery.  Granting 
the  truth  of  this  statement,  the  question  at  once  juices  as  to  just 
what  a  'compensatory  recovery'  is.  In  other  words,  what  do  we 
mean  when  we  say  thai  'compensation'  occurs  in  the  course  of  a 
hemorrhage  ? 

"Compensation  may  be  defined  as  being  the  natural  effort  of  the 
circulatory  system  to  maintain  a  normal  or  at  Leasl  efficient  blood 
pressure  after  diminution  of  the  efficient  vascular  content.  The 
phrase  'efficient  vascular  content'  is  used  advisedly  for  the  reason  of 
stnsis  in  the  vascular  trunks. 

"Eoughly  speaking,  compensation  is  noted  in  all  the  grades  of 
hemorrhage  until  such  a  degree  has  been  reached  thai  the  vasomotor 
center  is  no  Longer  actively  responsive  to  reflex  stimulation,  such  as 
burning  a  paw  or  stimulating  the  sciatic  nerve.  With  the  hemor- 
rhage and  the  fall   in  the  blood   pressure  the  specific  gravity  of  the 


HEMORRHAGE  107 

blood  falls.  After  the  hemorrhage  has  proceeded  until  there  is  no 
effort  at  compensation  the  animal  unaided  rarely  recovers.  If  the 
blood  pressure  is  raised  either  by  saline  infusion,  by  bandaging,  or 
by  the  administration  of  adrenalin,  sometimes  the  centers  become 
more  active,  and  the  blood  pressure  assumes  and  holds  a  higher  level. 

"In  experiments  in  which  the  hemorrhage  was  continued  until 
there  was  no  spontaneous  compensation,  and  there  was  no  response 
to  reflex  stimulation,  the  animal  could  rarely  be  made  to  recover. 
There  was  a  marked  difference  in  the  final  result  if  an  interval  inter- 
vened between  the  time  of  the  ending  of  the  hemorrhage  and  the  be- 
ginning of  treatment.  The  longer  the  interval  of  low  Mood  pressure 
the  less  marked  ivere  the  effects  of  treatment.  In  rapid  bleeding  the 
blood  pressure  continues  to  fall  after  the  cessation  of  the  hemorrhage. 
The  extent  of  the  recovery  depends  upon  the  individuality  of  the  ani- 
mal and  amount  of  the  hemorrhage.  The  proportion  of  lost  blood 
to  the  body  weight  that  animals  withstood  and  recovered  from  varied 
considerably  in  individual  cases.  This  degree  of  variation  seemed 
to  us  to  be  greater  than  is  usually  given.  In  some  animals  recovery 
occurred  when  three-fifths  of  the  estimated  blood  had  been  lost, 
while  in  others  death  would  occur  after  a  loss  of  two-fifths.  It  was 
impossible  to  estimate  in  any  given  animal  with  any  degree  of  ac- 
curacy the  proportion  of  blood  to  its  body  weight  which  it  might 
lose  and  recover. 

"What,  then,  are  the  secondary  factors  entering  into  the  fall  in 
the  blood  pressure  and  its  recovery  ?  It  may  be  assumed  that  the  pri- 
mary factor  is  anemia  with  consequent  lessening  of  the  immediate 
nutrition  of  the  active  physiologic  mechanism  for  the  maintenance 
of  the  normal  blood  pressure.  Among  the  secondary  factors  we  may 
assume  that  the  action  of  the  vasomotor  center  stands  first." 

Not  only  do  the  important  nerve  centers  suffer  impairment  of 
function  as  a  cause  of  acute  anemia,  but  all  authorities  agree  that 
cardiac  activity  is  satisfactory  only  as  long  as  there  is  a  sufficient 
volume  of  fluid  within  the  auricles  and  ventricles.  The  restoration 
of  the  blood  after  hemorrhage  was  studied  by  Kiefer,6  who  found 
that  the  red  corpuscles  were  restored  in  number  more  quickly  than 
was  the  percentage  of  hemoglobin.  Bierfreund7  found  the  regen- 
eration of  the  blood  to  commence  within  five  to  twenty  days  after 
the  rather  insufficient  loss  which  is  attendant  upon  the  average  sur- 
gical operation. 

Von  Mikulicz8  studied  regeneration  after  the  loss  of  large  amounts 
of  blood  and  found  compensation  to  be  as  follows : 

1.  Less  than  1  per  cent  of  the  blood  mass  in  two  to  five  days. 


108  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

2.  From  1  to  3  per  cent  of  the  blood  mass  in  five  to  fourteen  days. 

3.  From  3  to  4  per  cent  of  the  blood  mass  in  fourteen  to  thirty 
days. 

Diagnosis. — The  diagnosis  of  an  open  hemorrhage  or  one  of 
mixed  type  where  blood  follows  a  drain  to  the  surface,  needs,  of 
course,  no  extensive  comment.  It  becomes  quite  a  difficult  matter 
when  the  diagnostician  is  confronted  by  a  patient  who  appears  to 
be  failing  rapidly  after  a  difficult  and  prolonged  surgical  procedure ; 
then  the  problem  of  differential  diagnosis  between  shock  and  con- 
cealed hemorrhage  becomes  difficult,  or  as  many  of  our  most  experi- 
enced writers  agree,  well  nigh  impossible.  One  instance  in  my  ex- 
perience shows  how  difficult  it  may  be  to  differentiate  between  post- 
operative hemorrhage  and  perforation  of  a  hollow  abdominal  viscus: 

An  exclusion  of  the  pyloric  region,  together  with  a  gastroenteros- 
tomy had  been  done  for  ulcer.  A  few  days  later,  the  patient  rather 
suddenly  entered  a  state  of  seeming  collapse,  while  complaining  of  se- 
vere pain  in  the  epigastrium.  I  naturally  feared  that  a  stomach  suture 
line  had  given  way,  hence,  reopened  the  abdomen  immediately,  only 
to  find  the  upper  intestinal  coils  full  of  blood.  Fortunately,  in  this 
instance,  conservative  treatment  resulted  in  the  patient's  recovery, 
while  the  painful  incident  demonstrates  very  well  one  of  the  pos- 
sibilities of  error  in  the  diagnosis  of  concealed  hemorrhage. 

Almost  in  line  with  this  case  was  a  remark  which  I  once  heard 
W.  J.  Mayo  make,  as  a  part  of  one  of  those  delightful  and  instruc- 
tive clinical  talks  which  he  is  accustomed  to  make  in  the  operating 
room.  He  was  discoursing  on  shock,  and  surprised  us  all  by  stat- 
ing, in  his  cryptic  way,  that  he  had  usually  found  the  abdomen  full 
of  blood  at  autopsy  on  patients  who  had  died  of  shock  following  an 
abdominal  operation.  This  points  in  no  unmistakable  way  to  the 
relative  frequency  of  the  two  conditions. 

Matas  very  well  summarizes  the  leading  features  in  symptomatol- 
Ogy,  when  he  tells  us  that  the  picture  varies  directly  with  the  amount 
of  blood  lost,  the  rate  at  which  it  escapes,  and  with  its  location.  As 
a  matter  of  course,  the  symptoms  to  be  immediately  detailed  will  be 
more  impressive,  the  larger  the  hemorrhage,  or  more  rapid  the 
flow,  while  the  symptoms  attending  the  escape  of  a  given  amount  of 
blood  into  an  elastic  space,  like  the  peritoneal  cavity,  are  much  less 
alarming  than  those  which  attend  the  rapid  accumulation  of  the 
same  amount  in  the  fascial  planes  of  the  neck,  which  enclose  the 
trachea,  as  happened  a  few  hours  after  one  id'  my  goiter  operations 
previously  mentioned. 

The   effects   of   acute    anemia    make   themselves   known   in    several 


HEMORRHAGE  109 

ways.  The  heart  muscle  gets  a  decreased  amount  of  blood  through 
the  coronary  vessels,  hence,  is  unable  to  functionate  in  the  normal 
manner.  The  respiratory  center  is  stimulated  by  the  lack  of  oxygen 
and  we  see  the  expression  of  increased  respiratory  action,  which  is 
termed  "air  hunger." 

The  psychic  manifestations  of  cerebral  anemia  are  anxiety  and 
restlessness.  All  the  while  the  leucocyte  count  may  be  said  to  rise 
steadily  in  a  typical  case.  It  might  be  thought  from  the  foregoing 
that  a  diagnosis  of  concealed  hemorrhage  is  a  matter  of  mathematical 
certainty.  On  the  contrary,  I  have  seen,  at  least,  one  fatal  instance 
in  which  the  patient  was  perfectly  free  from  restlessness  and  "air 
hunger"  up  to  the  time  of  dissolution. 

The  picture  of  hemorrhage  is  not  complete  without  mention  at 
least  of  posthemorrhagic  anemia  and  its  consequences.  It  has,  how- 
ever, no  features  which  distinguish  it  from  chronic  secondary  anemia 
in  general,  hence,  no  space  will  be  devoted  to  it  here. 

The  treatment  of  hemorrhage  must  begin  with  preventive  measures. 
The  finding  of  a  high  blood  pressure  puts  one  on  guard  and  may  limit 
the  extent  of  a  surgical  procedure  that  would  seem  indicated  under 
the  circumstances.  If  the  clotting  time  of  a  patient's  blood  is  found 
to  be  longer  than  eight  minutes,  the  surgeon  should  be  on  the  alert 
for  a  dyscrasia,  which  might  allow  a  comparatively  simple  operation 
to  assume  formidable  proportions,  because  the  blood  refused  to  clot 
in  the  normal  way.  Hemostasis  is  favored  by  the  position  of  a  pa- 
tient on  the  operating  table.  This  was  vividly  impressed  upon  me 
while  a  student  in  Europe.  Lexer,  who  was  then  assisting  in  the 
Royal  Clinic,  was  engaged  in  the  removal  of  a  Gasserian  ganglion 
and  was  greatly  annoyed  by  venous  oozing.  His  chief,  Prof.  Von 
Bergmann,  entered  the  operating  room  by  chance,  and  suggested 
that  he  complete  the  operation  with  the  patient  in  the  sitting 
posture.  From  that  time  until  the  close  of  the  operation,  the  field 
remained  singularly  dry,  and  the  illustration  was  never  forgotten. 

The  prophylactic  use  of  pressure  on  large  arterial  trunks  during 
amputations,  goes  back  to  the  Dark  Ages  of  surgery,  while  the  use 
of  constriction,  for  example,  Esmarch's  bandage,  in  this  connection 
is  too  well  known  to  need  more  than  passsing  mention. 

Treatment. — The  treatment  of  actual  hemorrhage  is  logically  di- 
vided by  Matas  into  three  phases.  (1)  The  arresting  of  the  hemor- 
rhage; (2)  the  prevention  of  a  recurrence;  (3)  the  recovery  of  the 
patient.  The  actual  arrest  of  bleeding  is  accomplished  in  quite  a 
variety  of  well-known  ways.  The  application  of  a  clamp  and  a  liga- 
ture represents  the  ideal,  where  this  is  possible.    A  gauze  tampon,  the 


110  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

application  of  heat  or  other  cauterizing  agents,  such  as  hot  water, 
steam,  or  a  chemical  escharotic,  to  say  nothing  of  extreme  cold,  may 
accomplish  the  desired  purpose.  Guided  by  physiologic  considerations 
Sir  Victor  Horsley  checked  the  bleeding  from  small  vessels  by  plac- 
ing tiny  strips  of  detached  muscle  upon  them,  thus  liberating  a  fibrin 
ferment.  Among  the  less  well-known  local  means  of  arresting  hemor- 
rhage must  be  mentioned  Koeher's  eoagulin,  of  which  we  read  Aviclely 
differing  opinions.  Hess'1  made  extensive  use  of  free  omental  grafts 
in  the  control  of  hemorrhage  in  injured  abdominal  parenchymatous 
organs.  One  can  readily  see  the  advantage  of  suturing  omental  grafts 
around  a  spleen,  as  was  done  by  Dr.  Kirchner  of  St.  Louis.  As  a 
substitute  for  a  gauze  pack,  which  is  often  difficult  and  dangerous 
to  remove.  Yaeger  and  Wolgamuth  devised  a  web  of  a  substance 
similar  to  catgut,  derived  from  the  sheep's  intestine,  which  they 
successfully  paeked  into  bleeding  cavities.  The  absorbability  of 
this  mass  naturally  commends  it  to  our  attention. 

Hess  proposes  a  new  local  application  for  the  control  of  bleeding. 
Regarding  it,  I  shall  quote  directly  from  his  conclusions. 

"Tissue  juice  made  from  brain  (thromboplastin  solution)  has 
proved  itself  of  practical  value  in  controlling  hemorrhage  wherever 
it  can  reach  the  site  of  bleeding.  *  *  *  It  is  to  be  recommended 
for  local  use  in  the  parenchymatous  bleeding  associated  with  various 
operations,  etc.  Where  local  applications  fail,  it  should  be  injected 
into  the  site  of  hemorrhage,  as  in  bleeding  from  the  gums  following 
tooth  extraction.  *  *  *  It  is  innocuous  when  given  by  mouth  in 
considerable  dosage,  and  would  seem  to  he  indicated  in  bleeding  from 
the  stomach  and  from  the  upper  intestine." 

A  number  of  general  means  for  arresting  hemorrhage  have  been 
proposed  and  used  with  varying  degrees  of  success.  Lansberg  claims 
good  results  for  an  extract  of  corpus  luteum.  while  Weinstein  reports 
marked  success  in  twelve  cases  following  hypodermic  injections  of 
one-half  grain  emetine  hydrochloride.  Schreiber  made  intravenous 
injections  of  200  c.c.  of  a  5  to  20  per  cent  solution  of  grape  sugar, 
and  claims  to  have  checked  severe  gastric  and  intestinal  hemorrhage 
by  so  doing. 

One  to  two  per  cent  of  gelatin  dissolved  in  sail   solution  has  1 n 

rathe/  extensively  used  as  an  intravenous  injection.  However,  opin- 
ions differ  as  to  its  efficacy.  The  prevention  of  recurrence  of  hemor- 
rhage is.  perhaps,  best  illustrated  by  referring  the  reader  back  to  an 
illustration  of  hemorrhage  due  to  the  erosion  of  a  large  vessel. 

After  a  patient  lias  been  almost  exsanguinated  by  repeated  hemor- 
rhage from  a  branch  of  the  external  carotid,  we  not  onlv  succeeded 


HEMORRHAGE 


111 


Fig.   21-A. — The   simplest  means   of   increasing  the  amount   of   blood   in  the   heart  and   central 

nervous   system. 


Fig.   21-B. — A  posture   suggested   for  shock  and   hemorrhage   where   the   respiratory   apparatus 

is   full  of  mucus. 


112  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

in  stopping  the  bleeding,  but  prevented  any  renewal  of  it  by  ligating 
the  common  carotid  artery. 

One  of  the  most  logical  and  efficient  methods  at  our  command  in 
accomplishing  this  is  blood  transfusion,  which  so  alters  the  composi- 
tion of  the  patient's  blood  as  to  render  a  recurrence  much  less  likely. 
It  goes  without  saying  that  this  object  is  attained  by  keeping  the  pa- 
tient quiet,  for  which  purpose  morphine  is  invaluable.  The  means 
which  conduce  to  the  recovery  of  the  patient  are  legion,  and  most 
of  them  exceedingly  well  known.  The  relatively  little  blood  that  re- 
mains in  the  circulatory  system  must  be  sent,  first  of  all,  to  the  cen- 
tral nervous  system  and  the  heart,  hence,  we  employ  posture  (Fig. 
21A)  and  a  compression  of  large  veins  as  has  been  fully  described 
under  the  treatment  of  shock,  which  see. 

The  same  considerations  of  heat,  stimulants,  etc.,  obtain  here,  as 
in  the  chapter  just  mentioned,  therefore,  a  repetition  is  avoided  at 
this  time. 

In  acute  hemorrhage,  the  volume  of  fluid  in  the  circulatory  sys- 
tem must,  of  course,  be  augmented  as  early  as  possible.  This  must 
be  done  with  the  greatest  caution,  however,  unless  the  source  of  bleed- 
ing is  known  to  have  been  controlled.  Water  under  the  skin  or  into 
the  rectum  is  of  undoubted  value,  unless  the  hemorrhage  has  been  of 
excessive  amount.  Under  such  circumstances,  blood  transfusion  is 
the  only  remedy  at  our  command  which  will  save  the  patient's  life. 
The  technic  of  these  procedures  has  been  fully  discussed  in  special 
chapters  on  Hypodermoclysis,  Proctoclysis,  and  Transfusion. 

Bibliography 

iMatas,  Rudolph:     Keen's  Surgery,    Its   Principles  ami   Practice,   Philadelphia, 

and  London,  1911,  W.  B.  Saunders  Co. 
-Howell:     American  Textbook  of  Physiology,  1900  edition. 
stewavt:      A    Manual  of  Physiology,  1900  edition, 
'('rile.  Geo.  W.:     Hemorrhage  and  Transfusion.     An  Experimental  and  Clinical 

Research,  New  York  and   London,  1909,   D.  Appleton  &  Co. 
5Tillmans:     Text  Book  of  Surgery,   1901,  i.  465. 
"Kiefer,   G.  L. :      A  Study  of  the  Blood  after   Hemorrhage   ami   a   Comparative 

Study   of   Venous   and    Arterial   Blood   with   Reference   to    the    Number    of 

Corpuscles  and  the  Amount  of  Hemoglobin,   Med.  News,   New   York,   1892, 

lx,  22Y227. 
"Yon  Bierfreund:     Verhandl.  d.  deutsch.  Gesellsch.   f.  Chir.,  1890,  xix.  Part  2. 

pp.  159-221. 
•'Yon   Mikulicz:      Ueber    den    Hemoglobingehalt    bei    ehirurgischen   Erkrankun<jen 

mit  besonderer  Riicksicht  auf  den  Wiederersatz    von    Blutverlusten,    Wien. 

med.   Wchnschr.,   1890,  xl,  803. 
°Hess,  A.  F. :     A  Further  Report  on  Thromboplastin  Solution  as  a  Hemostatic, 

New  York. 


CHAPTER  XIV 

DILATATION  OF  THE  HEART  WITH  REFERENCE  TO 

POSTOPERATIVE  ACUTE  DILATATION 

By  Willard  Bartlett  and  Riley  M.  Waller,  St.  Louis,  Mo. 

The  best  informed  members  of  the  medical  profession  consider  the 
existence  of  acute  postoperative  cardiac  dilatation  a  question  which 
is  still  open  for  debate.  If  one  does  not  admit  such  an  entity,  how 
are  those  cases  which  show  soon  after  operation  all  the  classical 
signs,  both  clinically  and  at  autopsy,  to  be  classed? 

The  occurrence  of  such  a  condition  after  abdominal  operations  is 
reported  to  be  as  low  as  2  per  cent,  or  even  less,  in  some  clinics,  with 
a  much  higher  percentage  in  others.  Wertheim1  in  five  hundred 
consecutive  hysterectomies  for  cancer  had  ninety-three  deaths, 
twenty-nine  of  these  being  due  to  acute  dilatation  alone. 

Before  proceeding  further,  one  must  bear  in  mind  some  of  the 
characteristics  and  physiologic  factors  peculiar  to  the  heart.  It 
has  been  found  that  surgical  procedures  on  it  have  met  with  varied 
success — from  uneventful  operation  and  recovery  on  the  one  hand, 
to  serious  sudden  changes  in  action  or  even  stopping  in  a  similar 
operation.  Bad  results  can  often  be  avoided  if  the  procedure  be 
gradual,  because  the  heart  can  stand  considerable  trauma  and  hand- 
ling if  done  by  degrees.2 

Heart  muscle  is  a  tissue,  and  a  highly  specialized  one,  hence  it 
is  subject  to  fatigue,  toxins,  chemicals,  etc.,  perhaps  to  a  greater 
extent  than  some  less  specialized  ones.  When  one  recalls  that  the 
force  the  heart  developes  is  dependent  on  the  amount  of  blood  com- 
ing into  it,  also  that  the  force  is  in  a  geometric  ratio3  to  the  intake, 
it  is  only  reasonable  to  believe  that  the  heart  is  fatigued  when  those 
changes  occur. 

Having  recalled  these  facts,  it  would  seem  logical  to  consider  the 
causes  of  acute  dilatation :  1.  Previous  diseases  and  conditions 
are  known  by  all  to  affect  the  myocardium  to  a  greater  or  lesser 
extent,  and  to  operate  in  the  presence  of  such  cardiopathic  condi- 
tions is  not  without  risk.  Often  the  surgeon  must  decide  between 
the  dangers  of  the  surgical  condition  at  hand  and  that  of  operative 
procedure  in  face  of  a  weakened  myocardium.     Blackford,  Willis, 

113 


114  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

and  Haines,4  working  at  the  Mayo  Clinic,  have  found  that  (a)  a 
large  percentage  of  cardiopathy,  often  thought  hopeless,  could  he 
relieved  by  surgical  intervention;  (b)  that  most  surgeons  tend  to 
have  too  great  a  balance  of  cardiac  safety  on  their  side  to  be  of 
greatest  value  to  their  patients.  This  would  seem  quite  optimistic, 
but  those  findings  apply  only  to  select  cases.  This  immediately 
brings  up  the  question  of  a  standard  for  these  "selected  cases." 
It  must  also  be  remembered  that  the  facilities  for  handling  such 
cases  are  not  so  good  as  would  be  desired  in  many  clinics. 

2.  Turning  now  to  the  factors  that  may  affect  either  a  weakened 
or  a  clinically  normal  heart,  the  first  to  be  considered  is  the 
Trendelenburg  position.  It  has  long  been  known  that  the  extreme 
of  this  position  tends  to  raise  the  blood  pressure.  The  explana- 
tion of  this  is  that  the  blood  leaves  a  Large  splanchnic  area  and  the 
heart  must  respond  more  forcibly  and  faster  to  distribute  the  blood. 
Gatch,  (burn,  and  Mann5  found  experimentally  that  if  dogs,  in 
which  artificial  respiration  is  used,  were  deprived  of  this,  the  heart 
would  stop  beating.  Those  in  the  extreme  Trendelenburg  position 
slopped  in  two  and  three-fourths,  four  and  one-half,  three  and  one- 
half,  and  four  and  three-fourths  minutes,  respectively,  while  those 
in  the  horizontal  position  stopped  in  nine,  six  and  one-half,  and 
eight  minutes.  It  was  also  found  that  these  dogs  could  readily 
be  revived  by  massaging  the  heart  through  the  abdominal  wall. 
These  same  hearts,  after  resting,  were  again  treated  in  the  manner 
described  above  and  ceased  to  act  in  less  than  two  minutes.  In- 
stead of  giving  long,  forceful  beats,  as  in  the  first  trial,  they  showed 
rapid,  incomplete  contractions,  and  a  very  dilated  heart,  thereby,  in- 
dicating that  such  hearts  had  been  seriously  damaged  by  tin1  first  pro- 
cedure. 

3.  The  same  authors5  also  found  that  when  animals  struggled 
while  under  lighl  anesthesia,  the  hearts  showed  a  great  ballooning 
in  all  four  chambers.  They  soon  became  overdilated  and  ceased  to 
act.  Such  results  arc  similar  to  those  observed  by  Kay  and  Adami0 
in  1888  in  which  it  was  shown  that  increase  in  abdominal  pressure 
by  compression  increased  the  heart's  output  29.6  per  cent.  One 
can  also  imagine  the  effect  of  tigh.1  abdominal  packing  with  gauze 
and  of  struggling  during  the  operation. 

4.  In  case  (if  a  severe  hemorrhage  or  shock,  where  the  heart  mus- 
cle is  quite  anemic,  large  transfusions  or  injections  of  fluids  given 
rapidly  would  increase  the  heart's  output  tremendously  and  cause 
the  partially  degenerated  fibers  to  dilate.  Occasionally  such  acci- 
dents happen  during  these  procedures. 


DILATATION    OF    THE    HEART 


115 


5.  Crile3  suggests  that  increased  pulmonary  pressure  due  to 
forced  artificial  respiration  causes  considerable  difficulty  and  em- 
barrassment for  the  right  heart  in  forcing  blood  through  such  an 
impacted  organ.  Such  a  condition  is  certainly  analagous  to  the 
described  condition  of  hypertrophy  secondary  to  emphysema.  In 
addition,  this  process  is  more  sudden  and  violent,  hence  more 
serious  than  when  due  to  emphysema. 

6.  Finally  Vander  Veer7  presents  a  theory  backed  up  by  case 
reports  to  explain  the  condition  in  some  patients  at  least.  In  a 
series  of  postoperative  chronic  cholecystitis  and  appendicitis  in 
elderly  persons  it  was  found  that  in  a  small  percentage  of  these 
all  the  signs  of  acute  dilatation  developed  thirty  to  sixty-five  hours 
after  operation.  Rosenau  believes  that  there  is  a  specific  streptococ- 
cus in  those  organs  that  has  an  affinity  for  the  myocardium,  and 
claims  to  have  found  such.  They  suggest  culturing  the  contents 
of  such  organs  at  operation  and  preparation  of  stock  vaccines.  This 
work  is  not  conclusive,  and  further  experimentation  is  being  done. 

According  to  onset,  the  condition  may  be  designated  as  early  and 
late.  The  symptomatology  in  both  is  practically  identical,  (a) 
Early — this  includes  those  individuals  that  soon  die  after  transfu- 
sion and  injections  of  fluids  and  those  weakened  by  disease.  These 
fail  to  rally  after  operation  and  show  pulse  of  130  or  more,  which 
is  weak  and  irregular.  They  are  restless,  have  no  courage,  grow 
worse,  and  often  die  before  thirty-six  hours,  (b)  Late — this  group 
includes  those  that  have  apparently  stood  the  shock  and  strain 
of  the  operation  splendidly,  but  after  eighteen  to  sixty  hours  do 
poorly.  They  begin  to  show,  after  pulse  has  already  come  down  to 
100  or  less,  a  rapid  increase  of  twenty  or  more,  and  all  the  signs 
of  dilatation.  Decompensation  may  take  place  and  the  case  proba- 
bly end  fatally.  Before  one  makes  a  diagnosis  it  is  well  to  rule 
out  the  following  that  might  simulate  it :  hemorrhage,  atropine,  right- 
sided  hypertension,  dilatation  of  the  stomach,  or  rapid  absorption 
of  toxins  from  a  draining  wound. 

Pathology. — Grossly  such  hearts  are  often  brownish  in  color. 
The  walls  are  thin  and  flabby  and  show  an  increase  in  dimensions 
of  the  heart  chambers.  Microscopically  the  picture  may  be  iden- 
tical with  that  found  in  dilatation  following  a  break  in  compensa- 
tion in  a  previously  hypertrophied  heart.  As  to  the  details  one 
may  find  one  or  more  of  the  pathologic  conditions  seen  in  myocardial 
involvement  elsewhere.  In  other  cases  there  are  found  degenerated 
fibers  in  a  heart  that  has  not  previously  been  hypertrophied  or 


116  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

diseased  over  any  length  of  time.  Fragmentation  lias  never  been 
described. 

Diagnosis. — It  is  of  utmost  importance  that  the  surgeon  recognize 
the  condition  at  once  and  differentiate  between  shock,  cerebral 
anemia,  toxic  absorption,  drugs,  etc.  The  treatment  is  diamet- 
rically opposed  to  that  of  shock  and  cerebral  anemia,  hence  the  need 
of  diagnosis.  In  shock,  one  does  not  find  the  cardiac  area  enlarged, 
neither  dues  the  condition  manifest  itself,  as  a  rule,  except  at  op- 
eration or  very  soon  after.  Cerebral  anemia  would  be  present 
after  many  of  the  conditions  that  produce  acute  dilatation.  One 
would  also  expect  to  find  more  marked  mental  and  nervous  symp- 
toms. From  toxins  and  drugs  one  usually  has  the  records  and  re- 
ports as  guides  for  such  action. 

Treatment. — The  basis  of  all  treatmenl  is  to  relieve  the  heart  of 
as  much  strain  as  possible  by  decreasing  its  volume  output  and 
to  improve  the  condition  of  the  myocardium.  The  following  prin- 
ciples are  suggested  because  they  are  distinctly  indicated. 

1.  Of  greatest  importance  is  prevention  as  expressed  by 
thorough  preoperative  physical  examination  and.  after  having  once 
begun  the  operation,  to  keep  in  mind  the  factors  that  are  responsi- 
ble for  injury  to  the  heart. 

2.  The  horizontal,  or  better,  the  Fowler  position  tends  to  dilate 
the  large  splanchnic  area,  thereby  decreasing  the  volume  output 
of  the  heart. 

3.  Massage  in  hearts  that  are  about  to  stop  or  have  done  so  may 
be  a  life-saving  measure,  if  applied  properly  to  the  lower  anterior 
border  of  the  ribs  directing  the  force  upward  and  inward  to  the 
heart. 

4.  Bleeding  if  done  here  effects  one  of  the  few  conditions  in  modern 
practice  thai  is  favorable  tor  such  intervention.  This  offers  a  quick 
direct  means  of  relieving  the  load  on  the  heart.  The  amount  to  be 
drawn   is  much   a   matter  of  judgment    in   the   individual   case. 

5.  Cardiac  stimulants,  (a)  digitalis  in  massive  dos,.s.  (b)  aconite 
3  it|_  at  a  dose  until  desired  effects  on  the  pulse  are  obtained,  or 
(c)  strophanthus  8  11\.  at  a  dose  may  be  given  to  slow  and  to 
strengthen  the  pulse. 

6.  Absolute  bed  resi  is  to  be  enforced.  Opiates  are  to  be  Used 
in  large  enough  doses  to  keep  patient  quiet.  The  nurse  must  feed, 
bathe,  and  attend  to  all  tin1  patient's  personal  needs  until  out  of 
danger.  No  visitors  or  unnecessary  disturbances  of  any  kind  are 
to  be  allowed. 


DILATATION    OF    THE    HEART  117 

7.  "Withholding  of  fluids  and  mild  stimulation  and  elimination 
would  tend  to  reduce  the  volume  of  the  blood  and  for  that  reason 
are  indicated. 

8.  Diet.  Soft  low  protein  diet  during  the  acute  stage  would  be 
the  choice.  Food  in  concentrated  form  is  much  preferable  to  the 
more  bulky  ones  in  that  they  require  less  energy  for  absorption  and 
propulsion. 

Summary. — (T>  Acute  postoperative  dilatation  is  a  condition  that 
is  often  preventable,  and  can  be  brought  about  by  one  or  more 
recognized  factors.  (2)  That  accurate  diagnosis  and  treatment  is 
necessary  and  essential  at  the  earliest  possible  moment  for  the  best 
interests  of  the  patient. 

Full  credit  is  clue  Riley  M.  Waller  for  having  abstracted  all  the 
literature  to  which  reference  is  made  in  this  chapter. 

Bibliography 

lYVertheim :     Die    Erweiterte   Abdominale   Operation   bei   Carcinoma   Colli  Uteri, 

Vienna,  Urban  und  Sehwarzberg. 
2Simpson,  F.  F. :     Right-sided  Hypertension  with  Occasional  Cardiac  Dilatations 

and  Postoperative  Complications,  Jour.  Am.  Med.  Assn.,  1915,  lxv,  941-915. 
ECrile :   Keene  's  Surgery,  i,  79-82. 
<Blaekf  ord,   J.   M. ;    Willis,   F.   A. ;    Haines,   S.   B. :     Operative   Risk   in   Cardiac 

Disease,  Jour.  Am.  Med.  Assn.,  Ixix,  2011. 
sGateh,  W.   D.;    Ganu,   Dewell;    Mann,   F.   C. :      The   Danger   and   Prevention   of 

Severe  Cardiac  Strain     during  Anesthesia,  Jour.  Am.  Med.  Assn.,  April  26 

1919. 
fEay  and  Adami;  Brit.  Med.  Jour.,  Dec,  1888. 
7Vander  Veer,  E.  D.:     Dilatation  of  Heart  with  Acute  Myocarditis  Following 

Abdominal  Operations,  inn.  Surg.,   1917. 


CHAPTER  XV 

ACUTE  DILATATION  OF  THE  STOMACH 
By  o.  V.  MeKittrick,  St.  Louis.  Mo. 

This  condition  has  long  been  considered  a  definite  clinical  entity 
by  many  writers  on  the  subject.  As  early  as  1853,  Miller  and  Hum- 
ley1  reported  a  case  dying  from  such  a  malady.  The  autopsy  re- 
vealed an  unusually  distended  stomach,  the  small  intestines  being  con- 
tracted and  free  from  any  disease.  A  few  years  later  others  reported 
cases  in  which  the  phenomenon  was  noted.  In  1859,  Brinton-  re- 
ported more  eases  and  described  the  disease.  Even  at  that  date,  it  is 
recorded  that  the  affection  is  one  "exclusively  concerned  with  the 
stomach."  In  187:!.  Fagge3  discussed  the  symptoms  at  length  and 
first  advised  lavage  as  the  only  efficient  remedy.  Since  this  date, 
many  cases  have  been  reported. 

It  was  not  until  1892,  the  condition  was  really  recognized  as  an 
important  postoperative  complication.4  Three  years  later.  Selmitz- 
ler5  suggested  the  postural  treatment  in  addition  to  lavage.  In 
1907,  Conner6  reviewed  the  whole  subject  in  detail,  and  he  particu- 
larly influenced  the  surgeons  in  this  country  to  pay  more  attention 
to  the  condition  so  that  since  this  time,  considerable  thought  has 
been  given  to  the  accident.  Among  the  more  important  contributors  to 
the  literature  may  be  mentioned  Laffer,7  Chavannaz,8  Midler/'  and 
Payer.10  In  1913,  the  malady  was  again  subjected  to  a  critical  dis- 
cussion by  Ruth11  and  Borchgrevink.12  Another  valuable  paper  was 
added  in  1914.  by  Linke13  and  the  work  of  Lee"  brings  the  discussion 
of  the  subject  up  to  the  present  time. 

The  condition  occurs  far  more  frequently  than  had  been  observed 
in  the  past.  Tt  was  formerly  stated  by  Smith1"'  that  acute  dilatation 
was  never  reported  under  twenty  hours  after  the  operation.  Payer 
soon  after  Smith's  declaration,  was  able  to  definitely  determine  by 
examination  of  the  stomach  during  narcosis,  that  a  distinct  atony 
occurred  in  nearly  every  one  of  the  three  hundred  patients  whom  he 
studied  and  that  dilatation  immediately  followed  their  awakening 
from  the  anesthesia.  Furthermore,  he  found  that  the  paresis  did  not 
subside  for  from  twelve  to  fourteen  days  after  the  surgical  interfer- 
ence. Of  the  144  cases  reported  by  Borchgrevink,  (137  of  which  were 
collected  from  the  literature  since  1895)  66.2  per  cent  occurred  after 

lis 


ACUTE   DILATATION    OF    THE    STOMACH  119 

operations.  On  the  other  hand,  Laser's  review  of  the  literature,  which 
includes  those  cases  before  1895,  gives  only  38.2  per  cent  as  post- 
operative. 

The  nature  of  the  operation  which  particularly  predisposes  to  this 
malady,  is  laparotomy.  Of  Borchgrevink's  collection  78.8  per  cent, 
and  of  Laffer's  69  per  cent  occurred  after  opening  of  the  abdomen 
for  work  upon  the  female  genital  organs.  These  constitute  the 
largest  number,  which  is  closely  followed  by  surgical  procedures  in- 
volving the  biliary  systems.  Next  in  order  come  the  appendix,  and 
then  operations  upon  the  stomach  itself.  Acute  dilatation  after  the 
last  named  most  frequently  followed  gastrojejunostomy. 

Of  the  extra  peritoneal  operations,  those  upon  the  kidney  lead, 
with  the  extremities  following  next  in  order.  Herniotomies  and 
curettages,  and  even  operations  upon  the  face,  have  been  complicated 
by  this  malady. 

The  cases  studied  by  these  observers  were,  with  one  exception,  all 
subjected  to  a  general  narcosis,  ether  being  the  anesthetic  most  com- 
monly used.  The  kind  of  anesthetic  seemed  to  have  no  influence, 
however.  Lichtenstein16  states  that  the  condition  may  even  occur 
in  patients  who  were  not  given  a  general  anesthetic. 

As  to  the  time  dilatation  appears  in  surgical  patients,  Euth,  Lee,  and 
others  have  shown  that  it  may  occur  during  the  operation.  Lee  in 
his  paper,  reported  a  case  in  which  death  occurred  on  the  operating 
table,  due  to  this  phenomena.  He  also  included  five  other  cases  in 
which  the  malady  was  observed,  but  happily  did  not  terminate  fa- 
tally. 

The  symptoms  usually  commence  before  the  third  day.  The  larg- 
est number  of  recorded  cases  occurred  between  the  second  and  third 
days.  The  cases  occurring  within  the  first  twenty-four  hours  can 
hardly  be  estimated,  since  vomiting  due  to  the  narcosis,  so  often 
masks  the  symptoms  that  the  condition  is  not  recognized.  Cases 
have  been  recorded  much  later  than  the  third  clay.  Chavannaz  re- 
ported it  occurring  during  the  sixth,  Mayo  Robson,17  the  tenth, 
and  Nakaharals  the  sixteenth  postoperative  days.  In  Borchgrevink's 
case,  symptoms  did  not  appear  until  the  twenty-fourth  day  after 
operation.  Others  have  reported  the  malady  occurring  as  late  as 
the  thirtieth  postoperative  day. 

Cases  appearing  later  than  ten  days  after  an  operation  are  usually 
associated  with  some  intercurrent  infection,  and  should,  we  think, 
hardly  be  included  as  a  postoperative  complication.  The  complica- 
tion most  generally  occurs  in  thin,  weak  and  poorly  nourished  in- 
dividuals, and  especially  in  those  who  present  a  general  enteroptosis.19 


120  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

111  130  of  the  cases  in  which  sex  is  mentioned,  60  per  cent  occurred 
in  women.  The  most  common  age  was  between  thirty  and  forty 
years.  The  youngest  patient  was  a  boy  of  four,  and  the  oldest,  a 
woman  sixty-five  years  old. 

Many  theories  have  been  put  forth  to  explain  the  cause  of  this 
complication.  Individual  predisposition  has  been  considered  by 
some  to  have  considerable  influence.  Payer.  Chavannaz,  and  Linke, 
have  all  reported  successive  operations  upon  the  same  patient,  in 
support  of  this  view.  We  would  regard  such  a  theory,  as  Lee,  who 
says  it  is  too  indefinite  to  be  considered  seriously. 

Many  predisposing  factors  which  favor  the  condition  must  be 
thought  of  under  such  circumstances.  Among  these  may  be  men- 
tioned the  various  forms  of  nervous  and  digestive  disturbances, 
which  in  themselves  have  been  described  as  inciting  causes.  Gastro- 
ptosis.  enteroptosis,  and  even  hyperchlorhydria,30  have  also  been  con- 
sidered as  eausative  agents. 

Bavin20  and  Areangeli21  attribute  the  cause  to  a  functional  dis- 
turbance of  the  suprarenals.  with  lack  of  adrenaline,  which  regulates 
the  nervous  control  of  the  stomach. 

One  of  the  most  generally  accepted  theories  is  that  paralysis  of 
the  stomach  is  due  to  disturbed  innervation.  It  was  first  considered 
a  possible  cause  by  Brinton,  in  1859,  and  his  ideas,  more  or  less 
modified,  have  maintained  themselves  throughout  the  years.  In  1907, 
great  impetus  was  given  this  theory  by  the  work  of  Braun  and 
Seidel.22  By  experimentally  influencing  the  nervous  system,  an  atony 
of  the  stomach  may  be  produced,  also  lesions  of  the  nervous  system 
deprive  the  stomach  of  the  ability  to  empty  itself.  This  failure  of 
the  gastric  musculature  therefore  is  a  functional  disturbance.1"  Linke 
and  others  believe  that  without  continued  failure  of  the  musculature 
of  the  stomach,  dilatation  is  impossible. 

In  addition  to  those  mentioned.  Riedel  states  that  the  handling 
and  exposure  of  the  organ  during  abdominal  operations,  is  one  cause 
of  the  muscular  paresis.  Von  Herff  and  Kelling23  showed  that  in  a 
series  of  three  hundred  inhalation  narcosis,  the  great  majority  of 
the  patients  developed  some  grade  of  gastric  atony  and  dilatation. 
Von  Herff'24  attributes  this  to  poisoning  of  the  neuromuscular  mech- 
anism by  the  anesthetic.  If  this  persists  longer,  the  postanesthetic 
paresis  will  also  persist,  and  dilatation  of  the  stomach  is  naturally 
predisposed.  Linke  adds  that  the  paralysis  of  the  gastric  muscula- 
ture may  be  due  to  central  or  reflex,  as  well  as  peripheral  disturb- 
ances of  innervation.  Such  may  be  brought  about  by  mechanical  in- 
jury as  Riedel  already  mentioned,  or  by  toxic   influences  upon  the 


ACUTE    DILATATION    OF    THE    STOMACH  121 

muscle  fibers,  or  infection  of  same  or  by  both,  or  even  by  a  disturb- 
ance of  the  internal  secretion  governing  it,  as  was  pointed  out  by 
Kivin,  and  also  by  Arcangeli. 

Kundrat,25  in  1891,  states  that  the  primary  cause  of  acute  dilata- 
tion, was  compression  of  the  duodenum  by  the  mesentery  as  a  special 
form  of  high  strangulation.  Nine  years  later,  Mtiller  called  attention 
to  the  similarity  of  symptoms  in  cases  of  high  intestinal  obstruction 
and  those  of  acute  dilatation  of  the  stomach. 

Others  have  considered  paralysis  of  the  stomach  as  the  primary 
cause,  and  the  occlusion  of  the  duodenum  a  purely  mechanical  sec- 
ondary incidence.  This  is  brought  about  either  by  the  weight  of  the 
stomach  on  the  duodenum  as  it  crosses  the  spine,26  or  else  by  a  sec- 
ondary arteriomesenteric  compression,  brought  about  indirectly  by  the 
distended  stomach's  pressure  on  the  small  intestine.12 

Most  recent  literature  supports  the  swallowing  of  air,  in  addition, 
to  the  paralysis  theory,  as  the  most  likely  cause  of  this  malady.  Lee, 
particularly,  thinks  this  most  probable.  The  five  cases  which  he  col- 
lected, and  the  one  of  his  own,  certainly  bear  out  his  contention  that 
the  rapid  dilatation  of  the  stomach,  upon  the  operating  table,  could 
hardly  have  been  due  to  anything  but  gas  distention.  In  his  own 
case,  the  gas  may  have  arisen  from  food  fermentation.  It  is  well 
known  that  a  certain  amount  of  gas  is  normally  present  in  the 
stomach;  to  this  gas  may  be  added  that  from  the  duodenum,  that 
resulting  from  the  swallowing  of  ether,  or  that  formed  by  the  ex- 
cretion of  it  into  the  stomach,  during  an  ether  narcosis. 

The  position  of  the  patient,  in  addition  to  the  anesthesia,  more 
or  less  hinders  the  escape  of  the  gas  through  the  cardia.  But  despite 
these  various  ways  in  which  gas  may  collect  in  the  stomach,  it  is 
highly  improbable  that  a  sufficient  amount  can  be  formed  to  cause 
rapid  dilatation,  as  was  seen  in  Lee's  cases,  unless  the  patient  ac- 
tually swallows  air.  Many  observers  claim  to  have  noticed  the  pa- 
tient accomplish  this  feat  during  anesthesia.  The  stimulation  of  the 
salivary  glands  produces  an  increased  flow  of  saliva,  thereby 
causing  the  patient  to  swallow  more  frequently,  the  air  being 
carried  with  the  saliva  and  mucus  into  the  stomach.  In  aero- 
phagics,  the  symptoms  are  considered  most  marked,4  and  many  ob- 
servers claim  the  aerophagia  as  the  most  important  etiologic  factor. 
Among  them  may  be  mentioned  Tissier,27  Couto,28  Buchholz,29  and 
Lee. 

The  cases  of  acute  dilatation  of  the  stomach  which  come  to  autopsy 
always  present  the  organ  more  or  less  distended,  sometimes  only 
slightly,  and  at  times  this  viscus  is  so  inflated  that  it  reaches  the 


122  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

symphysis.  In  such  instance,  the  walls  are  extremely  thin,  showing 
the  contents  within.  It  usually  has  a  bluish  color,  and  at  times  small 
ulcers  or  erosions  can  be  found  in  the  mucous  membrane,  from 
which  the  bleeding  comes  which  is  seen  frequently  in  these  cases. 

The  small  intestines  are  usually  collapsed,  and  lie  in  the  pelvis. 
The  duodenum  is  occasionally  distended,  however,  but  usually  in 
its  upper  part  only. 

In  eases  in  which  gallstones  are  discovered,  adhesions  are  often 
present  between  gall  bladder  and  duodenum.  The  older  writers  con- 
sidered these  important  as  a  primary  cause  for  the  distention.  The 
arteriomesenteric  compression  above  noted  is  mentioned  b}'  a  few 
authors  as  one  of  the  autopsy  findings.  It  was  found  by  Payer,  Con- 
ner, Box  and  Wallace,  and  others. 

The  outcome  in  these  cases  was  formerly  almost  always  fatal.  Con- 
ner's statistes.  which  were  published  in  1907,  showed  a  mortality 
of  72.5  per  cent.  Laffer,  who  reported  his  statistics  in  1908,  showed 
a  decrease  to  63.5  per  cent.  Borchgrevink's  in  19b!.  gave  only  51.1 
per  cent.  This  latter  statistician  showed  that  the  death  rate  is  only 
26.2  per  cent  in  the  cases  reported  since  1907.  He  does  not  include 
the  patients  which  were  treated  by  surgical  operation,  stating  that 
the  mortality  under  such  circumstances  was  100  per  cent. 

The  length  of  time  in  which  death  supervened,  was  from  several 
hours,  to  sixteen  days  after  the  tiist  symptom.  Usually  it  occurs 
within  two  days.  If  the  patient  lives  this  long,  the  chances  for  get- 
ting well  are  50  per  cent  better.  Of  :;i  untreated  cases  of  acute  post- 
operative dilatation  collected  by  Borchgrevink,  (some  received  medi- 
cine. 29  died;  2  alone  escaping.  One  was  treated  with  apomorphine, 
and  the  other  given  hypodermoclysis.12 

The  symptoms  depend  upon  the  seriousness  of  the  case,  and  the 
condition  in  which  the  patient  was  before  the  dilatation  occurred. 
The  puresl  form  occurs  after  a  less  serious  operation,  before  which 
the  patient  has  felt  fairly  well. 

Usually  the  first  sign  of  any  trouble  is  a  feeling  of  fullness  in  the 
epigastrium,  associated  with  an  uneasiness  which  quickly  develops 
into  actual  pain.  This  grows  more  and  more  intense,  depending 
upon  the  extent  of  the  dilatation.  Patients  have  screamed  with  pain, 
day  and  night,  others  have  moaned  continually,  while  in  rare  in- 
stances, very  little  or  no  pain  was  complained  of. 

With  the  beginning  of  the  distention  in  the  upper  abdomen,  the 
pulse  quickens,  and  the  face  becomes  anxious.  Eiccough  may  now 
occur.  Some  patients  become  dizzy,  while  all  complain  of  thirst 
which  continues  with  increasing  severity,  the  longer  the  malady  lasts. 


ACUTE    DILATATION    OF    THE    STOMACH  123 

Vomiting  now  commences.  It  occurs  at  frequent  intervals,  and  is 
usually  free  of  the  retching  seen  in  ordinary  vomiting;  a  portion  of 
the  contents  of  the  stomach  comes  up  without  much  strain  or  effort, 
the  fluid  suddenly  filling  the  patient's  mouth,  which  he  empties.  If 
the  stomach  tube  is  now  inserted,  more  fluid  will  be  obtained  than 
the  amount  which  the  patient  has  vomited.  The  amount  vomited  at 
a  time  is  usually  not  very  great,  6  to  12  ounces,  probably,  but  the 
tube  will  bring  up,  at  times,  large  quantities  of  fluid,  aggregating 
occasionally  six  or  more  liters.  The  secretion  quickly  reforms.  Mor- 
ris30 considers  the  increased  secretion  of  the  gastric  mucosa  a  very 
important  point  in  the  disease.  The  vomiting  persists  throughout 
the  time  the  stomach  is  dilated,  ending  usually  a  few  hours  before 
death.  In  some  instances,  no  vomiting  occurs.  Such  cases  while  in- 
deed remarkable,  are  not  rare.  The  outcome  is  probably  less  favor- 
able in  the  absence  of  this  symptom. 

The  contents  of  the  stomach  consists  of  gas,  mixed  with  a  yellow- 
ish or  greenish  odorless  watery  fluid.  In  the  operative  cases  dis- 
cussed by  Lee,  an  odorless  gas  alone  was  noted.  As  the  vomiting  con- 
tinues over  several  hours,  it  becomes  brownish,  and  finally  black 
from  the  admixture  of  blood.  It  now  grows  offensive,  presenting  a 
nauseating,  sweetish  smell.  In  addition  to  the  blood,  bile  is  present, 
This,  seemingly,  is  a  constant  finding.  Fluid  which  does  not  show 
blood,  will  contain  bile.  Hydrochloric  acid  is  very  much  diminished 
in  many  cases,  and  at  times,  lactic  acid  may  be  associated  with  it. 
Various  bacteria  have  been  found  in  sporadic  cases,  but  the  nature 
of  the  disease  will  largely  determine  the  stomach  contents,  partic- 
ularly if  the  primary  disease  be  in  this  organ. 

The  quantity  of  fluid  secreted  during  such  a  condition  is  large, 
as  already  stated.  The  stomach  dilates  rapidly,  and  the  capacity 
is  enormously  increased  within  a  very  short  time.  A  normal  stom- 
ach may  expand,  so  as  to  reach  the  pubis  within  twenty-four  to 
forty-eight  hours.1  Such  a  phenomenon  may  even  transpire  within 
a  very  few  hours.19  Usually,  there  is  not  a  symmetrical  distention  of 
the  abdomen,  and  the  outlines  of  the  gas  in  the  stomach  can  be  seen 
or  determined  by  percussion.  Further  examination  of  the  abdomen 
will  reveal  tenderness,  particularly  in  the  epigastrium,  which  reaches 
its  maximum  during  the  early  stages  of  the  dilatation.  Succussion  or 
splashing  sounds  are  elicited,  and,  at  times,  peristalsis  may  be  seen. 
The  tumor-like  mass  disappears  on  inserting  the  stomach  tube. 

Symptoms. — The  general  condition  of  the  patient  remains  com- 
paratively good,  despite  the  constant  vomiting.  The  chief  symp- 
toms, according  to  Borchgrevink,  are  the  abdominal  distress  caused 


124  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

by  the  actual  stretching  of  the  musculature,  and  the  continual  thirst. 
The  urine  is  scanty.  Cyanosis  may  occur.  In  the  severe  cases,  or 
even  in  the  milder  cases,  which  have  been  progressing  nicely,  there 
may  suddenly  occur  symptoms  of  collapse,  followed  in  a  few  mo- 
ments by  death.  Such  early  symptoms  do  not  occur  frequently,  but 
as  a  rule,  a  few  hours  will  intervene,  even  in  the  worse  cases,  before 
such  an  end  results.  In  the  meantime,  the  pulse  becomes  thready, 
fast,  and  easily  compressible;  the  blood  pressure  falls,  the  eyes  be- 
come sunken,  the  skin  cold  and  clammy,  with  other  attendant  symp- 
toms of  shock.  A  few  instances  have  been  reported,  in  which  the 
first  symptoms  were  those  of  collapse. 

The  intestines,  in  many  instances,  continue  with  their  normal 
functions,  but  a  more  common  observation  is  that  all  passing  of  flatus 
and  bowel  movements  cease.  Diarrhea  has  been  recorded  accompany- 
ing the  dilatation  of  the  stomach. 

Treatment. — The  treatment  consists  first  of  all  in  preventing  too 
free  catharsis  in  weak,  debilitated  patients,  before  they  come  to  the 
operation.  During  the  surgical  procedure  the  possibility  of  this 
complication  must  not  be  ignored,  and  in  patients  in  whom  the  mal- 
ady is  likely  to  occur,  all  preparations  must  be  made  beforehand  for 
a  timely  lavage.  At  the  end  of  every  stomach  or  gall  bladder  opera- 
tion, the  stomach  should  be  washed  with  plain  cold  tap  water,  in 
order  to  clear  out  any  gas  or  fluid  which  may  have  accumulated 
during  the  oarcosis.  In  many  instances,  our  patient  is  sent  back  to 
bed  with  the  tube  in  place,  and  the  stomach  washed  cwvy  two  or 
three  hours  with  cold  water,  until  all  nausea  and  vomiting  erase. 

When  the  condition  occurs  on  the  operating  table,  lavage  will 
quickly  and  surely  relieve  it.  Such  a  measure  has  not  in  itself  been 
so  successful  in  the  convalescing  patient.  Where  the  tube  alone  was 
used,  50  per  cent  of  the  eases  reported  by  Borchgrevink  died. 

The  essential  treatment  then,  includes  not  alone  this  effective  meas- 
ure of  keeping  the  stomach  free  of  gas  and  fluid  by  frequent  washings, 
but  a  constant  changing  of  the  position  must  be  carried  our.  The 
most  comfortable  posture  for  the  patient  is  on  the  abdomen  A  pil- 
low under  the  chest  will  make  him  more  comfortable.  After  he  has 
lain  this  way  for  an  hour,  he  is  changed  to  his  right  side,  and  at  the 
end  of  another  hour,  to  the  left  side,  and  then  on  the  abdomen  or 
back,  as  most  desired  by  the  sufferer. 

The  thirst  is  controlled  by  giving  continuous  proctoclysis  of  plain 
tap  water,  which  is  made  into  a  f>  per  cent  glucose  solution.  Also 
continuous   hypodermoclysis   of  physiologic   salt   solution,   or   plain, 


ACUTE   DILATATION    OF    THE    STOMACH  125 

freshly  distilled,  sterile  water  instead  of  salt  solution,  may  be  em- 
ployed. 

Under  no  circumstances,  give  anything  by  mouth.  Ice  held  in 
the  mouth,  and  all  water,  spat  out,  or  a  little  mineral  oil  will  keep 
the  mouth  from  becoming  too  dry  and  parched,  and  will  in  great 
measure,  assist  in  allaying  the  thirst.  Every  case  showing  symp- 
toms and  signs  of  this  very  common  condition,  must  at  once  be 
energetically  treated,  with  infinite  care  for  details  regarding  the 
comfort  and  well  being  of  the  patient. 

When  the  viscus  has  returned  to  the  normal  dimensions  and  po- 
sition, the  abstinence  from  food  or  drink  per  mouth  should  be  con- 
tinued for  several  hours  longer,  as  everyone  with  experience  knows 
that  even  the  smallest  amount  of  any  fluid  may  initiate  symptoms 
again. 

As  to  the  drugs  which  may  be  used,  probably  intramuscular  or  in- 
travenous pituitrin  is  the  most  efficacious. 

Bibliography 

iMiller  and  Huniley:     Tr.  Path.  Soc,  London,  1853,  iv,  137. 

2Brinton:      Diseases  of  the  Stomach,  London,  1859,  p.  343. 

3Fagge:     Guy's  Hosp.  Reports,  London,  1873,  series  3,  xviii. 

*Riedel :     Erf ahrungen  ueber  die   Gallen-stein  Krankheit  mit  und  ohne  Icterus, 
Berlin,  1892,  p.  129. 

sSchnitzler:     Wien,  klin.  Rundschau,   1895,  ix,   580. 

sConner:      Am.   Jour.   Med.   Sc,   1907,   cxxxiii,   345. 

7Laffer:     Ann.  Surg.,  1908,  xlvii,  395. 

sQiavannaz:     Jour,  de  Med.  de  Bordeaux,  1909,  xxxix,  5. 

oMuller:     Deutsch.  Ztschr.  f.  Chir.,  1900,  lvi,  490. 

loPaver:     Mitt.  a.  d.   Grenzgeb.  d.  Med.  u.   Chir.,  1910-1911,  xxii,  411. 
uRuth:     Am.  Jour.  Obst.,  1913,  lxvii,  530. 
isBorehgrevink:      Surg.,  Gynec.  and  Obst.,   1913,  xri,  662. 
isLinke:     Beitr.  z.  klin.  Chir.,  1914,  xciii,  360. 
"Lee:     Ann.  Surg.,  1916,  lxiii,  418. 
isSmith:     Boston  Med.  and  Surg.  Jour.,  1909,  clxi,  529. 
isLichtenstein :     Centralbl.  f.  Gynak.,  1908,  xxxiii,  615. 

17Robson   and  Moynihan:      Diseases   of  the   Stomach   and   Their   Surgical   Treat- 
ment, London,  1904,  ed.  2. 
isXakahara:     Beitr.  z.  klin.  Chir.,  lxi,  593. 
isBorehardt :     Berlin  klin.  Wehnsehr.,  1908,  xlx,  1593. 
soKivin:     Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1911,  xxiii,  169. 
21Arcangeli:     Quoted  by  Fagge,  Lee,  and  Linke. 

22Braun  and  Seidel:     Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1907,  xvii,  533. 
ssVon  Herff  and  Kelling:      Quoted  by  Linke. 
2*Von  Herff:     Ztschr.  f.  Geburtsh.  u.  Gynak.,  1901,  xliv,  251. 
25Kundrat:     Wien.  med.  Wehnsehr.,  1891,  Xo.  8. 
26Box  and  Wallace :     Lancet,  London,  June,  1901. 
27Tissier:     Bull.  gen.  de  therap.  1910,  clix,  61. 

2SCouto:     Bull,  et  mem.  Soc.  med.  d.  hop.  de  Paris,  1914,  series  3,  xxxvii,  522. 
29Buehholz:      These,  Paris,   1912-1913,   Xo.  291,  p.   120. 
3<>Morris:     Boston  Med.  and  Surg.  Jour.,  1911,  clxiv,  564. 


CHAPTER  XVI 

POSTOPERATIVE  ILEUS 
By  Willard  Bartlett,  St.  Louis.  Mo. 

Sir  Fredrick  Treves1  wrote,  late  in  the  last  century,  that  two  thou- 
sand people  die  every  year  in  England  of  intestinal  obstruction.  More 
striking-  is  the  recent  statement  of  Roser,  that  four  thousand  deaths 
occur  every  year  in  Germany,  from  this  same  cause. 

Ileus  had  been  known,  and  was  recognized  even  earlier  in  the  his- 
tory of  medicine,  but  it  was  not  until  the  end  of  the  seventeenth  cen- 
tury, that  its  anatomic  characteristics  were  cleared  up.  AVe  have 
been  accustomed  to  define  it  as  a  malady  characterized  by  certain 
cardinal  symptoms;  however,  most  surgeons  wili  agree  with  Wilms2 
that  it  is  better  to  call  tbis  disease  a  serious  disturbance  of  the  in- 
testinal motor  function,  in  view  of  the  fact  that  one  or  more  of  the 
cardinal  symptoms  are  net  always  present  early  in  the  malady. 

It  is  difficult  to  treat  this  as  an  entity,  since  it  may  lie  defined  in 
so  many  different  ways,  for  instance,  it  is  seen  in  an  acute  form, 
which  presents  characteristics,  wholly  different  from  those  of  the 
chronic  recurring  variety.  It  may  he  imnn  diati .  that  is,  appearing 
within  a  few  days  after  an  operation,  or  the  onset  may  he  several 
years  later. 

Mortality. — The  mortality  in  the  postoperative  variety  of  ileus 
varies  somewhat  with  different  authors,  hut  may  be  roughly  stated 
as  being  about  •"">()  per  cent,  where  reoperation  has  been  undertaken 
after  a  lapse  of  several  days;  whereas  it  has  been  a  little  less  than 
one-half  this  distressing  figure,  in  consequence  of  timely  interference. 
These  figures  constitute  a  resume,  of  statistics  by  Deaver  and  Ross,3 
Coley,4  Xaunyn/'  Pilcher,6  Ruge.r  Brown,8  and  Kirchner.9 

Pseudoileus. — Before  proceeding  to  a  consideration  of  true  post- 
operative intestinal  obstruction,  it  seems  best  to  consider  separately, 
the  temporary  paresis  of  the  intestinal  tract,  which  is  so  frequently 
seen  following  abdominal  operations,  which  varies  considerably  in 
different  instances,  and  was  long  ago  given  the  name  pseudoileus,  by 
( Mshausen.10  This  condition  is  to  be  clearly  differentiated  from  true 
obstruction,  although  it  must  be  admitted  that  it  may  run  the  entire 
gamut  of  severity,  from  simple  distention,  to  paralytic  ileus  itself. 
It  is  exceedingly  common,  and  in  its  simplest  form,  follows  the  rough 

126 


POSTOPERATIVE    ILEUS  127 

handling,  prolonged  exposure,  and  undue  cooling  of  the  abdominal 
viscera.  There  are  individuals,  so  constituted  nervously,  as  to  seem 
particularly  susceptible  to  it. 

Symptoms. — The  symptoms  of  this  condition  are  distention,  and 
inability  to  pass  gas,  with  or  without  the  rhythmical  so-called  gas 
pains,  often  nausea,  and  vomiting.  The  patient  is  restless,  anxious, 
and  frequently  difficult  to  control.  The  condition  may  simulate  true 
intestinal  obstruction,  but  may  be  often  distinguished  from  the  lat- 
ter by  a  consideration  of  all  the  circumstances  which  obtained  pre- 
vious to,  and  at,  the  operation. 

Prognosis. — The  prognosis  is  ordinarily  good,  varying,  of  course, 
with  the  intelligence  and  discrimination  displayed  in  the  treatment, 
and  the  condition  may  usually  be  considered  rather  disturbing  than 
dangerous.  No  doubt  spontaneous  recurrence  takes  place  in  very 
many  neglected  instances.  Where  death  results  from  any  cause  what- 
soever, no  morbid  anatomic  condition  can  be  demonstrated,  so  far 
as  the  intestinal  tract  is  concerned.  It  must  be  added,  that  the  same 
thing  is  true  of  certain  types  of  true  ileus,  to  be  immediately  de- 
scribed, thence  the  reader  will  see  how  difficult  it  is  to  always  make 
a  hard  and  fast  distinction  between  pseudoileus  and  the  true  condi- 
tion. 

Treatment. — The  treatment  of  the  condition  begins  with  prophy- 
laxis, the  principal  point  in  this  connection  being  the  proper  use,  or 
perhaps  better,  the  nonuse,  of  drastic  purgatives,  just  before  opera- 
tion, says  Schubert.  The  condition,  we  believe,  is  seen  distinctly  less 
frequently  after  the  use  of  enemas  than  after  castor  oil,  immediately 
before  operation.  AVe  realize  perfectly  well,  that  there  are  condi- 
tions which  demand  prolonged  and  thorough  catharsis,  but  the  rou- 
tine use  of  these  drugs,  prior  to  operating,  is  often  as  senseless  as  is 
failure  to  individualize  anywhere  else,  in  medicine.  After  pseudo- 
ileus  has  commenced  it  is  frequently  not  a  simple  matter  to  over- 
come it  by  the  use  of  cathartics  by  mouth,  since  they  are  vomited 
almost  as  soon  as  given.  It  is  perhaps  better  to  use  highly  stimulat- 
ing enemas  of  a  volume  so  small  that  they  do  not  add  to  the  patient's 
distention.  In  this  connection,  we  have  found  enemas  of  pure  gly- 
cerin in  doses  of  one  to  two  ounces,  to  be  most  efficient  in  starting 
peristalsis.  The  same  may  be  said  of  six  ounces  of  freshly  prepared 
milk  of  asafetide,  as  enema — the  last-named  drug  has  a  marked  in- 
fluence in  quieting  the  patient  as  well.  A  rectal  tube,  left  in  place 
for  a  long  time,  seems  to  greatly  aid  some  individuals  in  passing  gas. 
As  a  matter  of  course,  stomach  lavage  will  relieve  distention,  and 
thus  minimize  embarrassment  of  circulation,  as  well  as  of  respiration. 


128  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

It  cau  not  be  too  highly  recommended  for  patients  who  have  a  dia- 
phragm markedly  pushed  upward.  A  patient  who  has  resisted  every 
therapeutic  measure  intended  for  the  relief  of  gas,  will  often  point  the 
way  to  his  own  salvation  by  begging  to  get  out  of  bed  onto  the  com- 
mode. We  were  greatly  surprised,  in  early  years,  to  see  such  patients 
freely  expel  feces  in  sitting  posture,  after  they  had  seemed  wholly 
unable  to  do  so  in  bed.  Physostigmine  in  the  large  dose  of  %5  of  a 
grain,  hypodermieally,  has  proved  of  the  greatest  value  in  my  hands, 
while  more  recently,  pituitrin  has  been  strongly  advocated  in  this 
connection. 

Classification  of  True  Ileus. — There  are  a  number  of  possible 
classifications,  though  probably  none  of  them  are  wholly  satisfactory. 
The  one  which  we  shall  follow  seems  to  make  the  subject  understand- 
able and  is  a  combination  of  those  that  have  seemed  to  us  most  logical. 

I.  Dynamic  (Functional)  Ileus 

(a)  Paralytic. 

(b)  Spastic. 

(c)  Hirschsprung's  disease. 

(d)  Thrombosis  and  embolism 

of  mesenteric  vessels. 

II.  Mechanical  Ih  us 

(a)  Strangulation. 

(b)  Obduration. 

(c)  Volvulus,  knots. 

(d)  Caused  by  Meckel's  diverticulum. 

(e)  Kinking. 

(f)  Strictures. 

A  brief  analysis  of  the  various  forms  of  (I)  dynamic  ileus,  is  per- 
haps in  order:  the  paralytic  variety  occurs  most  frequently  by  far,  in 
consequence  of  peritonitis.  It  also  follows  pressure  upon  or  squeezing 
of  intestinal  coils  at  operation.  Its  oriuin  is  more  obscure,  when 
it  follows  degenerative  conditions  of  the  central  nervous  system, 
or  is  seen  as  a  reflex  manifestation  of  acute  pancreatitis,  hematoma  at 
the  root  of  the  mesentery,  twisting  of  an  abdominal  organ  or  turn  on 
its  pedicle,  biliary  obstruction,  rupture  of  a  solid  abdominal  viscus, 
fracture  of  spine  or  pelvis,  or  retroperitoneal  suppuration.  It  is 
common  enough,  after  urine,  bile,  or  blood  has  collected  in  the  peri- 
toneal cavity,  and  sometimes  accompanies  intestinal  ulceration.  It 
may  be  added,  that  paralytic  ileus  can  indirectly  complicate  diseases 
of  any  abdominal   organ. 

The  spastic  form  of  dynamic  ileus,  has  been  noted  most  frequently 
in  hysterical  individuals.     Wilms  saw   it   in   a  tabetic  patient,  while 


POSTOPERATIVE    ILEUS  129 

Murphy  encountered  it  in  a  man  suffering  from  lead  colic.  It  has 
appeared  in  those  afflicted  with  intestinal  worms,  and  has  followed 
Littre's  hernia,  not  infrequently.  Hirschsprung's  disease  is  marked 
by  a  most  obstinate  retention  of  intestinal  contents  in  the  enormously 
distended  colon.  The  extent  of  bowel  affected,  varies  greatly  in  dif- 
ferent individuals. 

Thrombosis  and  embolism  of  the  mesenteric  vessels  though  com- 
paratively rare  following  surgical  operations  is  nevertheless  one  of 
the  most  serious  complications  with  which  we  have  to  deal. 

Yirchow20  in  1847  apparently  was  the  first  to  describe  occlusion 
of  the  mesenteric  vessels.  His  work  aroused  little  interest  and  it 
was  not  until  1875  that  the  clinical  picture  was  adequately  described 
by  Litten.21  Investigations  which  were  now  begun  in  earnest  re- 
sulted in  valuable  contributions  being  made  to  the  literature  by 
Cohnheim,  Cohn,  Oswald,22  Corner,23  Falkenberg24  and  others.  Un- 
til 1902,  64  cases  of  thrombosis  were  recorded,  49  of  these  being 
arterial.  Since  this  time  Jackson,  Porter,  and  Quinby23  have  col- 
lected 214  cases,  and  given  an  extensive  review  of  the  subject.  Re- 
cently Laplace,26  Killiani,  Woolsey,  Greensburg  and  Parker  Syms, 
have  each  reported  cases  suffering  from  this  disease.  Sym's  case  was 
ready  for  dismissal  from  the  hospital  when  this  complication  devel- 
oped, ending  fatally  within  a  few  hours.  This  affection,  according 
to  Corner,  is  most  common,  in  men  past  middle  life  in  whom  mitral 
disease  is  present,  though  endocarditis  equally  plays  an  important 
part.  Arterial  thrombosis  is  most  apt  to  follow  operations  in  those 
cases  associated  with  arteriosclerosis,  endocarditis  or  atheroma  of  the 
aorta,  while  venous  thrombosis  usually  occurs  primary  or  secondary 
to  thrombosis  of  the  portal  veins.  .-;_ 

As  to  the  relative  frequency,  Corner  further  states  that  the  arter- 
ies are  five  times  more  liable  to  be  involved  than  the  veins  and  that 
the  superior  mesenteric  artery  was  found  at  autopsy  to  be  thrombosed 
40  times,  where  the  inferior  mesenteric  was  involved  once. 

Occlusion  of  the  vessels  of  the  intestines  produces  a  hemorrhagic 
infarct  in  the  greatest  majority  of  cases.  Depending  upon  the  du- 
ration of  the  complication,  a  simple  hyperemia  with  superficial  nec- 
rosis may  occur,  or  an  absolute  gangrene  of  the  intestines  with  per- 
foration and  localized  peritonitis  with  pus  formation  may  be  pre- 
sented. In  the  most  fulminating  type,  gangrene  may  occur  within 
forty-eight  hours.  In  other  cases  this  may  not  be  present  for  several 
weeks.  In  most  cases  fluid  will  be  found  at  autopsy  in  the  peritoneal 
cavity  while  the  mesentery  swollen  and  edematous,  will  contain  hem- 


130  AFTER-TREATMENT   OP    SURGICAL   PATIENTS 

orrhages  of  various  sizes  between  its  layers,  and  there  may  be  marked 
enlargement  of  the  mesenteric  glands. 

Under  II,  mechanical  ileus,  let  us  consider  first,  very  briefly,  the 
various  causes  of  strangulation.  Coils  of  intestine  sometimes  become 
caught  after  operations,  through  openings  in  the  omentum,  mesen- 
tery, mesocolon,  or  broad  ligaments.  Pathologic  strands  and  bands 
of  all  sorts,  form  frequently,  giving  rise  to  a  similar  accident.  Next 
come  the  hernias,  inguinal,  femoral,  umbilical,  and  incisional,  to 
say  nothing  of  the  rarer  examples,  such  as  those  into  the  obturator 
opening,  and  the  foramen  of  Winslow. 

Obturation  implies  a  plugging  of  the  bowel  lumen,  in  almost  any 
way.  We  have  seen  this  occur  twice  following  the  forming  of  a  fecal 
stone,  twice  as  the  result  of  an  enormous  gallstone  sloughing  directly 
out  of  the  gallbladder  into  the  bowel,  and  once,  when  a  gauze  pad 
that  had  been  left  in  the  abdomen,  found  its  way  into  the  intestine. 
Others  have  seen  it  when  due  to  an  accumulation  of  intestinal  worms. 

Obturation  may  be  due  to  any  tumor  of  the  intestinal  wall,  but 
particularly  to  one  attached  by  a  small  pedicle.  There  are  forms  of 
external  pressure  upon  the  intestine,  which  are  difficult  to  classify, 
but  which  perhaps  most  nearly  approximate  obturation.  The  vari- 
ous forms  of  intussusception  may  all  be  considered  under  this  head. 
We  saw  one  unusual  case  of  this  kind,  in  which  a  small  cancer  at 
the  end  of  Meckel's  diverticulum,  caused  a  complete  invagination  of 
this  appendage,  and  acted  as  the  head  of  the  column,  down  the  colon. 

Volvulus  is  most  common  in  the  small  intestine.  It  can  rather 
easily  occur  to  a  sigmoid  with  a  long  mesentery,  while  a  volvulus  of 
the  ileus-cecal  region,  with  complete  obstruction,  was  seen  and  suc- 
cessfully treated  in  my  own  hands,  by  anastomosing  the  head  of  the 
cecum  to  the  sigmoid. 

Meckel's  diverticulum  may  interrupt  the  function  of  the  intestine 
in  a  variety  of  ways.  I  have  seen  it  tied  in  a  knot  around  a  loop  of 
small  bowel.  It  may  become  adherent  and  kink  the  bowel  at  its  at- 
tachment. It  is  rather  subject  to  diverticulitis,  and  can  also  cause 
an  intussusception. 

Kinking  of  the  intestine  is  one  of  the  commonest  forms  of  obstruc- 
tion. This  usually  results  from  adhesions,  and  is  now  less  common 
than  in  earlier  times,  when  the  peritonization  of  stumps  and  pedicles 
was  given  less  consideration  than  is  now  the  case. 

Strictures  are  prone  to  produce  a  chronic  recurring  form  of  ileus. 
They  follow  ulcerative  conditions,  but  are  much  more  frequent  dur- 
ing the  growth  of  a  carcinoma. 

Of  course,  any  variety  of  ileus  may  attack  the  patient  who  has 


POSTOPERATIVE    ILEUS  131 

been  operated  upon,  just  as  it  may  the  individual  who  is  in  perfect 
health,  hut  certain  types  of  obstruction  have  been  a  direct  con- 
sequence of  intraabdominal  operations,  thence  I  shall  devote  espe- 
cial attention  to  them,  while  adhering  to  the  general  classification  of 
the  subject.  The  dynamic  form  of  the  disease  (I)  is  very  much  more 
common  after  operation,  because  peritonitis  of  some  extent  is  so  very 
frequently  encountered.  I  have  seen  instances,  too  numerous  to  men- 
tion, as  is  unfortunately  true  of  all  operators.  Paralysis  of  the 
bowel  occurs  where  the  nutrient  blood  vessels  have  been  injured  at 
operation :  it  has  followed  removal  of  mesentery  tumors,  and  affected 
the  transverse  colon  after  resections  of  the  stomach,  during  which 
the  vessels  in  the  mesocolon  were  damaged. 

Under  II,  mechanical  form,  strangulation  is  common  in  certain 
situations.  Small  bowel  rather  frequently  slipped  through  an  open- 
ing in  the  transverse  mesocolon,  in  the  early  days  of  stomach  surgery, 
before  we  learned  to  suture  this  membrane  closely  around  the  site  of 
a  posterior  gastroenterostomy.  Numerous  strangulations,  resulting 
in  death,  are  on  record.  The  same  is  true  of  the  internal  Alexander 
operation,  and  of  uterine  suspension,  in  both  of  which  operations,  a 
patulous  ring  has  been  left  by  some  operators.  After  intestinal  re- 
section, the  wedge-shaped  defect  in  the  mesentery  has  not  always 
been  sutured,  and  the  same  accident  has  resulted. 

Obturation  ileus  has  been  less  frequent  perhaps,  as  a  postoperative 
complication.  I  know  of  one  instance,  in  which  a  laparotomy  pad 
of  large  size  was  left  in  a  peritoneal  cavity,  with  immediate  result- 
ing obstruction,  due  no  doubt  to  pressure  and  something  akin  to 
obturation,  while  a  true  case  of  this  kind  has  been  cited  above,  in 
connection  with  a  gauze  pad,  which  found  its  way  into  the  gut. 

Volvulus  produces  postoperative  obstruction  most  commonly,  as 
a  recurrence  after  unsatisfactory  operations  for  this  very  condition. 

Meckel's  diverticulum  is  perhaps  uncommonly  the  cause  of  this 
condition  during  a  surgical  convalescence. 

Kinking  of  the  bowel,  and  obstruction  has  been  most  frequent  at  a 
remote  period  after  the  formation  of  adhesions  to  improperly  covered 
stumps  in  the  pelvis.  I  know  of  one  instance  in  which  a  complete  ob- 
struction persisted  for  years  after  the  sigmoid  became  attached  in  this 
manner.  Fortunately  the  condition  was  completely  relieved  by  a  sec- 
ondary operation.  Too  extensive  inversion  of  an  appendix  stump  is 
known  to  have  resulted  in  kinking  at  the  ileocecal  junction,  with  such 
interference  as  to  necessitate  a  remote  secondary  operation.  The  rather 
modern  procedure  of  removing  the  gall  bladder  has  been  responsible 
for  the  duodenum  becoming  adherent  in  the  defect,  so  that  chronic 


132  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

pyloric  obstruction  has  resulted,  in  many  instances.  We  have  more 
than  once  been  driven  to  secondary  gastroenterostomy  for  the  treat- 
ment of  this  condition. 

Strictures,  "while  uncommon  as  a  cause  of  postoperative  ileus,  may 
be  seen  after  careless  suturing,  and  the  production  of  too  broad  a 
diaphragm  in  the  making  of  an  end  to  end  intestinal  anastomosis. 
The  very  nature  of  the  human  bowel  makes  this  accident  unlikely, 
still  it  is  somewhat  difficult  to  avoid  in  experimental  work  on  the 
dog.  This  animal  possesses  a  gut  which  is  exceedingly  thick  walled 
in  relation  to  its  diameter.  Perhaps  the  most  familiar  example  of 
remote  postoperative  ileus,  due  to  stricture,  is  the  variety  which  fol- 
lows secondary  jejunal  ulcer,  after  gastroenterostomy.  It  is  partial 
in  nature,  and  is,  no  doubt,  to  some  extent,  the  result  of  spasm. 

Symptoms  and  Diagnosis. — The  four  cardinal  symptoms  of  ileus 
are  inability  to  move  the  bowel  or  pass  gas,  colicky  abdominal  pain, 
feculent  vomiting,  and  meteorism.  Tins  presupposes  a  typical  out- 
spoken ease.  The  patient  is  anxious,  restless,  and  in  evident  dis- 
tress, as  a  rule.  The  rate  of  pulse  and  respiration  are  increased,  the 
face  is  pinched  and  dusky,  while  in  the  later  stages,  the  extremities 
are  cold,  and  the  abdomen  likely  to  be  boardlike  and  tender.  This 
superficial  description  of  the  disease  holds  good  for  any  late  case, 
no  matter  whether  it  belongs  originally  to  the  dynamic  or  to  the 
mechanical  variety,  since  obstruction  can  not  remain  complete  for 
any  length  of  time  without  the  intestinal  wall  becoming  pervious  to 
germs,  which  ultimately  produce  a  peritonitis,  thus  adding  the  ele- 
ment of  paralysis  to  the  already  existing  condition.  Hence  it  comes 
about  that  a  late  diagnosis  between  dynamic  and  mechanical  ileus  is 
impossible.  In  an  early  case  it  should  be  possible  for  a  trained  ob- 
server to  differentiate  between  the  two. 

A  diagnosis  of  functional  ileus  will,  in  any  case,  be  greatly  facili- 
tated by  an  exact  history  and  a  knowledge  of  all  the  circumstances 
which  attended  the  original  operation.  It  may  lie  said,  in  general. 
that  there  is  diffused  pain,  fever,  constipation,  an  abdomen  that 
is  tender  all  over,  and  uniformly  distended.  There  is  general 
muscular  hypertension.  The  vomiting,  which  characterized  this  con- 
dition, has  long  been  termed  "slopping  over,"  from  the  fact  that  it 
has  little  projecting  force.  It  is  almost  incessant,  the  greenish  fecu- 
lent fluid  escaping  a  mouthful  at  a  time.  Pain,  of  an  excruciating 
degree,  has  been  noted  in  those  cases  of  dynamic  ileus  which  we  have 
seen  caused  by  interference  with  intestinal  blood  supply.  So  striking 
has  been  this  manifestation  in  rare  instances,  as  to  lead  to  an  accurate 
diagnosis. 


POSTOPERATIVE    ILEUS  133 

111  early  mechanical  obstruction,  no  matter  what  the  exact  cause, 
certain  fairly  characteristic  phenomena  are  to  be  noted.  The  pain 
is  more  localized,  and  definitely  cramplike.  The  tenderness  is  also 
confined,  while  the  distention  is  limited  to  intestinal  coils,  which  in 
a  thin-walled  abdomen,  can  be  readily  outlined,  and  peristaltic  waves 
be  quite  as  readily  seen.  The  muscles  are  absolutely  boardlike, 
while  the  vomiting  has  a  projectile  quality,  which  may  carry  it  to  a 
considerable  distance.  Large  quantities  are  emitted  at  a  time,  with 
evident  effort  of  a  distressing  nature. 

The  diagnosis  of  the  exact  anatomic  form  of  mechanical  obstruc- 
tion must  be  very  rare.  One  point,  not  to  be  forgotten  in  this  con- 
nection, is  that  chronic  recurring  obstruction,  especially  in  an  elderly 
individual,  frequently  spells  cancerous  stricture  of  the  large  bowel. 
The  subject  of  diagnosis  can  not  be  dismissed  without  one  caution, 
namely,  time  should  never  be  wasted  in  trying  to  do  more  than  es- 
tablish a  mere  differential  diagnosis  between  the  dynamic  and  the 
mechanical  forms  of  the  malady,  since  the  treatment  of  the  two  is 
essentially  different.  It  must  be  borne  in  mind  that  the  patient  looks 
to  his  medical  adviser  for  the  speediest  possible  treatment  in  this 
condition,  rather  than  for  a  completely  satisfactory  diagnosis. 

Mechanism  and  Cause  of  Symptoms. — We  must  confess  to  a 
rather  meager  knowledge  of  the  finer  details  of  ileus.  We  do  not 
know  at  all,  how  the  reflex  forms  of  the  dynamic  variety  are  con- 
nected with  the  original  lesion,  in  a  given  case;  indeed,  the  inflam- 
matory variety,  the  one  most  frequently  seen,  is  not  wholly  clear  to 
us,  since  we  have  no  means  of  telling  whether  toxic  agents  directly 
affect  intestinal  musculature,  or  accomplish  the  same  thing  indirectly 
through  the  sympathetic  nerve  supply. 

Murphy  and  Vincent,12  after  a  series  of  experiments,  conclude,  in 
agreement  with  many  other  investigators,  that  the  acute  symptoms 
are  caused  by  the  toxic  substance,  which  they  found  in  the  obstructed 
loops.  Very  interesting  suggestions  as  to  the  cause  of  death  in  these 
instances,  have  emanated  from  McLean,13  who  is  not  satisfied  with  the 
toxin  theory;  but  noting,  as  he  does,  a  marked  loss  of  weight  dur- 
ing the  illness,  believes  death  clue  simply  to  dehydration,  which  oc- 
curs as  a  consequence  of  the  persistent  and  copious  vomiting.  He 
substantiates  his  position  by  the  observation  that  an  obstructed  ani- 
mal which  is  given  saline  infusions  lives  much  longer  than  the  con- 
trol animal  which  is  not  so  treated. 

Treatment. — In  the  treatment  of  true  ileus,  as  opposed  to  the 
somewhat  indefinite  pseudoileus  considered  above,  one  must  distin- 
guish sharply  between  the  dynamic   (functional),  and  the  median- 


134  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

ical  varieties,  since  the  entire  conception  of  the  two  is  as  different  as 
are  the  causes.  We  shall  take  up  the  dynamic  form  first,  and  reserve 
the  mechanical  for  separate  consideration.  As  above  stated,  dynamic 
ileus  results,  in  the  majority  of  instances,  from  peritonitis,  which 
under  the  conditions  of  modern  surgery,  is  encountered,  of  course, 
at  the  original  operation,  and  not  caused  by  it.  In  this  connection, 
the  prophylactic  plan  of  Andrus14  attracts  attention.  This  author, 
after  draining  a  peritonitis  case,  in  which  ileus  might  readily  super- 
vene, attaches  a  distended  loop  of  bowel  to  the  edge  of  his  incision, 
and  drains  it  primarily,  thus  accomplishing  in  advance,  a  measure 
which  might  later  be  demanded  as  life  saving.  Where  postoperative 
dynamic  ileus  already  exists,  the  indication  is  a  perfectly  definite 
one,  namely,  to  treat  the  cause,  and  in  most  instances,  the  ileus  will 
take  care  of  itself,  this  means  that  a  peritonitis,  if  localized,  must  be 
treated  by  drainage  under  local  anesthesia,  of  course,  since  the  in- 
testinal paresis  of  general  anesthesia  can  only  add  fuel  to  the  fire. 
Peritonitis  of  a  mild  degree,  or  one  in  which  no  localization  is  possi- 
ble, is  nowadays  universally  treated  by  the  Ochsner  method,  namely, 
by  placing  the  bowel  at  absolute  rest,  with  morphine,  and  thus  pre- 
venting dissemination.  The  indication  here  is  clean  cut,  in  that  the 
peritonitis  must  be  treated,  rather  than  the  bowels  moved.  This  dis- 
tinction is,  however,  not  always  made,  and  the  tired  horse  is  whipped 
when  he  ought  to  be  rested,  so  to  speak.  It  is  not  only  futile,  but 
little  short  of  a  crime  to  attempt  purgation  in  these  cases.  By  so 
doing,  one  succeeds  only  in  embarrassing  the  overloaded  stomach  and 
upper  intestinal  tract.  The  chief  physiologic  need  here  is  for  water, 
since  not  only  is  none  absorbed  from  the  stomach  walls,  but  hyper- 
secretion from  the  upper  digestive  tract  rapidly  dehydrates  the  pa- 
tient. As  long  as  he  "slops  over,"  lavage  must  be  practiced  every 
two  or  three  hours,  and  his  ever-increasing  thirst  he  assuaged  by 
water  in  the  rectum  and  under  the  skin. 

We  must  not  content  ourselves  with  the  above-mentioned  treat- 
ment any  length  of  time  in  the  presence  of  increasingly  severe  symp- 
toms, hut  after  a  few  hours  employ  the  one  sovereign  remedy  at  our 
command,  that  is,  a  fecal  fistula.  This  is,  of  course,  always  done 
under  local  anesthesia,  and  may  in  many  instances  be  advanta- 
geously combined  with  drainage  of  the  peritoneal  cavity.  I  think 
all  of  us  must  agree  with  Thompson,15  that  resection  has  no  place 
in  the  surgery  of  dynamic  ileus,  when  caused  by  peritonitis,  which 
again  reminds  us  of  the  importance  of  sharply  differentiating 
between  the  two  cardinal  forms  of  this  malady.  When  a  segment  of 
intestine  is  paralyzed,  in  consequence  of  damage  to  its  blood  supply, 


POSTOPERATIVE   ILEUS  135 

the  patient's  life  can  be  saved  in  only  one  way,  that  is,  by  resection. 
In  one  instance,  I  successfully  operated,  early  in  thrombophlebitis 
of  the  mesenteric  vessels,  where  there  was  beginning  gangrene  of 
two  yards  of  small  intestine. 

Mechanical  ileus,  in  any  of  its  many  forms,  demands  treatment  of 
a  mechanical  nature.  Wilms,  in  the  most  exhaustive  treatise  ever 
written  on  this  subject,  feels  that  the  prophylaxis  consists  largely  in 
the  prevention  of  visceral  agglutinations  and  adhesions.  There  must 
then  be  no  cooling  or  drying  of  areas  which  it  is  necessary  to  handle 
and  expose.  Sepsis  and  limited  necrosis  must  be  prevented,  and  the 
use  of  tampons  restricted  to  the  minimum,  all  peritoneal  rings  are  most 
carefully  to  be  sutured,  and  exposed  surfaces  to  be  painstakingly 
covered  by  peritoneum.  Very  early,  gentle  catharsis  will  accomplish 
wonders  towards  the  prevention  of  adhesion  to  damaged  visceral 
surfaces.  Eeichekloerfer16  voices  an  ingenious  suggestion,  which  may 
be  of  value :  he  gets  his  patients  into  a  sitting  posture  as  early  as 
possible  after  abdominal  operations,  feeling  that  adhesions  which  may 
form,  will  do  less  than  the  usual  harm,  by  holding  the  patient's 
viscera  in  the  position  to  which  they  are  accustomed  while  he  is  up 
and  employed.  Keilty17  reminds  us  that  we  were  on  the  wrong  track, 
years  ago,  when  we  filled  the  peritoneal  cavity  with  oils  and  other 
foreign  substances  in  the  hope  of  preventing  adhesions  during  the 
reparative  period. 

Given  a  patient  suffering  from  mechanical  obstruction,  there  are 
two  procedures  possible,  both  of  them  operative ;  one,  drainage  of 
the  embarrassed  bowel,  and  the  other  removal  of  the  cause.  The 
choice  of  procedure  is  taken  out  of  a  surgeon's  hands  by  finding 
nutritional  changes  in  the  intestinal  wall.  He  has  then  no  recourse 
but  resection  of  the  affected  area.  In  the  absence  of  this  anatomic 
change,  the  general  condition  of  the  patient  will  always  be  his  guide 
as  to  whether  he  shall  do  a  drainage  operation  or  proceed  to  radical 
treatment  of  one  of  the  many  definite  conditions  which  may  bring 
about  this  form  of  ileus. 

If  an  artificial  anus  is  decided  upon,  it  should,  of  course,  be  made 
as  low  down  as  possible  in  the  obstructed  area,  however,  it  will  be 
done  only  on  a  very  sick  patient,  hence  the  first  distended  coil  that 
presents  itself  is  usually  thankfully  chosen  by  the  operator.  The  ce- 
cum is  by  all  means  to  be  elected,  if  the  obstruction  be  low  enough, 
since  attachment  of  it  to  the  abdominal  parietes  is  not  at  all  likely  to 
cause  future  kinking.  This  choice  has  the  further  advantage  of  leaving 
the  midline  and  left  side  free  for  a  secondary  attack  upon  the  ob- 
structing cause.     I  have  made  extensive  use  of  lateral  intestinal  an- 


136  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

astomosis  as  a  substitute  for  feeal  fistula,  with  most  gratifying  re- 
sults, in  dangerously  sick  patients  where  the  obstruction  was  high 
enough  to  reveal  '"flat,"  as  well  as  distended,  intestinal  coils.  This 
is  done  under  local  anesthesia,  with  the  utmost  ease,  and  is  from  the 
patient 's  viewpoint,  vastly  preferable  to  a  disgusting  fistula,  but  is,  of 
course,  not  to  be  undertaken  when  there  is  blood  in  the  peritoneal  cav- 
ity, or  where  other  evidence  of  a  nutritional  disturbance  is  present. 
This  procedure  is  further  recommended  by  the  well-known  physiologic 
consideration  that  a  lateral  intestinal  opening  drains  only  as  long  as 
obstruction  persists;  thence  we  have  every  reason  to  believe  that 
function  is  often  reestablished  in  any  intestinal  segment  thus  tem- 
porarily excluded. 

No  matter  what  operation  is  undertaken,  the  anesthesia  is  a  mat- 
ter of  the  greatest  importance.  The  intestinal  drainage  can,  of 
course,  be  done  under  local  anesthesia,  but  it  will  be  insufficient  if 
the  abdomen  is  to  lie  explored  and  a  radical  maneuver  executed.  A 
matter  of  greatest  importance  is  stomach  lavage,  just  before,  and 
during  a  general  anesthesia,  sinee  many  a  patient  is  drowned  in  his 
own  vomit,  early  in  the  administration  of  a  general  anesthetic,  in 
careless  hands. 

The  degree  of  evisceration,  while  searching  for  the  cause  of  ob- 
struction, is  fully  appreciated  only  by  the  surgeon  who  has  learned, 
through  bitter  experience,  to  appreciate  the  narrow  margin  of  re- 
sistance possessed  by  obstructed  patients.  It  is  furthermore  an  un- 
necessary maneuver,  since  the  entire  small  bowel  can  readily  be  in- 
vestigated, by  replacing  it,  a  little  at  a  time,  as  it  is  withdrawn.  This 
pre-supposes  a  knowledge  of  the  direction  in  which  one  is  working, 
but  this  can  be  readily  acquired  by  thrusting  the  hand  down  to  the 
root  of  the  mesentery,  which  is  disposed  almost  parallel  to  the  spinal 
column,  and  remembering  that  the  current  of  an  attached  intestinal 
loop  follows  the  up  and  down  direction  of  the  mesenteric  root. 

After  one  has  found  the  obstruction,  lie  may  be  aided  in  his  de- 
cision upon  radical  measures,  by  recollecting  that  von  Mikulicz,18 
the  master  of  intestinal  surgery,  experienced  a  mortality  of  40  per 
cent,  in  resection  of  obstructed  colon,  but  did  the  same  operation 
in  the  interval,  with  only  10  per  cent  loss.  It  is  a  much  disputed 
matter,  as  to  whether  one  is  justified  in  emptying  the  intestine  on  the 
operating  table.  No  doubt  it  is  theoretically  desirable  that  we  rid 
the  patient  of  toxic  material,  still  one-  is  surely  not  warranted  in  the 
use  of  any  complicated  or  time  consuming  method,  which  has  this 
end  in  view.  There  is,  no  doubt,  a  happy  medium  somewhere  between 
the  two  extremes.     1   have  at  times  found  it  distinctly  advantageous 


POSTOPERATIVE    ILEUS  137 

to  puncture  intestines  in  facilitating  their  return  to  the  cavity.  My 
experience  leads  me  to  believe  that  surgeons  have  exaggerated  the 
danger  of  dumping  contents  of  obstructed  coils  into  empty  ones, 
lower  down:  this  is  borne  out  by  the  experimental  work  of  Murphy 
and  Brooks,19  who  found  that  absorption  was  hastened  in  proportion 
to  intestinal  damage. 

The  need  of  water  in  the  treatment  of  a  patient  can  not  be  em- 
phasized too  strongly.  It  must  be  liberally  given  in  the  rectum  and 
under  the  skin,  as  outlined  in  connection  with  dynamic  ileus. 

Let  us  suppose  the  surgeon  to  have  found  a  mechanical  obstruction 
in  a  patient  whose  condition  permits  of  radical  surgery :  what  he 
does  next  must  conform  wholly  to  the  special  needs  inherent  to  the 
kind  of  mechanical  condition  presented. 

(a)  Strangulation  is,  of  course,  to  be  relieved  by  cutting  a  band, 
dividing  a  ring,  or  in  some  other  manner  releasing  the  damaged 
coil  and  restoring  it  to  its  accustomed  habitat.  It  is  most  difficult 
to  state  conditions  under  which  resection  is  to  be  done  for  impending 
gangrene.  My  own  observations  incline  me  to  think  that  we  have 
erred  in  being  too  radical,  rather  than  too  conservative.  Where 
there  is  the  slightest  doubt  about  its  future,  a  damaged  coil  is  by  all 
means  to  be  wrapped  in  rubber,  and  replaced  for  twenty-four  hours, 
after  which  time,  if  nothing  untoward  happens,  the  abdominal  wall 
can  be  completely  sutured.  There  will,  of  course,  be  no  question 
about  the  treatment  of  an  already  gangrenous  segment. 

(b)  Obturation  necessitates  the  removal  of  the  bolus  in  question. 
I,  personally,  have  removed  an  enormous  stone  from  the  jejunum,  a 
fecal  stone  the  size  of  a  lemon,  from  the  sigmoid,  and  an  obstructing 
gauze  pad  from  an  unidentified  coil. 

(c)  Volvulus  is  usually  successfully  treated  by  reposition  and 
fixation,  although,  in  one  instance  I  cured  a  recurring  affection  of 
the  ileocecal  region  by  anastomosing  the  head  of  the  cecum  with  the 
sigmoid. 

(d)  Meckel's  diverticulum  presents  so  great  a  variety  of  patho- 
logic conditions  that  it  can  hardly  be  briefly  treated  here. 

(e)  Kinking  may  sometimes  be  easily  relieved  by  dividing  an  ad- 
hesion or  may  at  times  demand  a  plastic  operation,  similar  to  the 
Finney,  or  others,  which  are  well  known  in  the  pyloric  region. 

(f)  Strictures,  if  benign,  are  also  amenable  to  plastic  operations, 
but  if  malignant,  they  demand  resection. 

The  prognosis  of  mechanical  intestinal  obstruction  is  frequently  a 
matter  of  the  utmost  uncertainty,  since  one  never  knows  just  when 
a  lethal  dose  of  toxin  has  been  absorbed.    I  have  seen  patients  grad- 


138  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

ually  sink  and  die  from  patent  failure  of  eerebro-vital  centers,  sev- 
eral days  after  an  operation,  which  not  only  accomplished  complete 
anatomic  restoration,  but  was  followed  by  the  restoration  of  gastro- 
enteric functions  of  every  kind. 

Bibliography 

iTreves:      Intestinal  Obstruction,   1901,   Cassell  and  Co. 

-Wilms :      Der  Ileus,  Stuttgart,  1906,  Verlag  von  Ferdinand  Enke. 

sDeaver  and  Ross:     Ann.  Surg.,  Feb.,  1915. 

*Coley,  W.  B. :     Keen 's  Surgery,  iv,  50. 

sNaunyn:     Keen's  Surgery,  iv,  p.  645. 

ePileher:     Med.  News,  1902. 

-Ruge:     Arch.  f.  klin.  Chir.,  1910,  xeiv,  711. 

sBaown,  J.  Y. :      Surg.,  Gynec.  and  Obst.,  1910,  xii,  186. 

9Kirchner,  W.  C.  G.:      Tr.  Am.  Assn.  Obst.  and  Gynec.,  1914. 
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Billroth,  1879. 
i 'Schubert,   G.:      Ztschr.   f.   Geburtsh.   u.   Gyniik.,    191  a,   lxxiii,  500;    Zentralbl.   f. 

d.    ges.   Gynak.  u.   Gelmrtsh.   s.   d.   Grenzgeb. 
i2Murphy  ami   Vineent:     Boston  Med.  ami   Surg.  .lour..  1911. 
isMeLean,  A.;      Postoperative  Ileus,  Am.  Surg.,   1914,  lix. 
i  lAmlrns,  R.  < '. :      Jour.  Michigan  Med.  Soc,  1915,  xiv,  86. 
isT/hompson:      Surg.,  Gynec.   and   Obst.,   1916,  xxii,  688. 

icReicheldoerfer,    L.    H.:      Postural   Treatment   of   Post-operative   Abdominal  Ad- 
hesions, Surg.,  Gynec.  and  Obst.,  191.".,  xvi,  755. 
I'K'cilty:      New    York    Med.   Jour.,    1915,  ci,   549. 

L8Von    Mikulicz:     Handbuch    der    Praktischen    Cliirurgie,    von    Bergmann,    von 

Bruns,  und   von   Mikulicz,  Stuttgart,    L900,   veil,  von   Ferdinand  Enke. 
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CHAPTER  XVII 

FAT  EMBOLISM 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Fat  embolism  not  infrequently  follows  operations,  particularly 
orthopedic  operations,  and  since  the  malady  has  attracted  so  little  no- 
tice in  the  country  until  the  last  few  years,  it  seems  fitting  that  at- 
tention should  again  be  called  to  this  important  subject. 

The  first  contributions  to  fat  embolism  date  back  to  the  seventeenth 
century.  Lower  in  1669  injected  19  ounces  of  milk  into  the  veins  of  a 
dog,  the  animal  dying  soon  after  in  a  spasm  with  all  the  signs  of  pro- 
found dyspnea.  Later,  similar  injections1  were  undertaken  for  va- 
rious purposes  by  Clark,  Corton,  King,  Drelincourt,  Gaspard  and 
Beck.  All  these  observers  reported  fatal  respiratory  disturbances  but 
in  none  of  the  experiments  were  the  lungs  of  the  animals  examined.. 
Magendie2  was  the  first  to  inject  pure  oil  into  the  veins,  and  as  a  conse- 
quence of  his  experiments,  was  the  first  to  prove  that  the  lung  capillar- 
ies can  be  plugged  with  fluid  fat.  Weber3  and  Schwick4  in  an  effort  to 
determine  the  effect  of  various  emulsions  on  the  circulation  when  in- 
jected intravenously,  found  that  embolism  did  not  follow  such  a  pro- 
cedure in  their  series  of  experiments.  By  injecting  oil  into  the  neck 
veins  of  a  dog,  Virchow5  succeeded  in  finding,  at  the  autopsy,  many 
small  fat  emboli  in  the  lungs  and  kidneys.  H.  Muller6  was  apparently 
the  first  to  discover  fat  embolism  in  the  human  subject.  In  cases  of 
chronic  interstitial  nephritis,  he  is  accredited  with  having  found  fat 
droplets  in  the  chorioid  vessels.  Zenker7  and  Wagner8  were  the  first 
to  observe  fat  emboli  in  the  lung  capillaries  (Fig.  22),  following  the 
accidental  fracture  of  several  ribs  and  rupture  of  the  liver  in  a  man. 

Considerable  interest  was  now  excited  and  many  men  investigated 
this  subject,  notable  among  whom  were  Hohlbeck9  and  von  Berg- 
mann.10  At  this  time  Busch11  first  definitely  proved  that  the  origin 
of  the  fat  in  these  cases  could  be  the  bone  marrow.  Some  time  later 
Flournoy12  proved  Wagner's  theory  that  fat  embolism  can  occur  after 
injury  to  the  fat  containing  soft  parts  while  Fritz  made  an  independ- 
ent demonstration  of  the  same  phenomenon.  During  the  latter  part 
of  the  nineteenth  century  Schriba13  collected  all  the  clinical  and  ex- 
perimental data  on  this  subject.    His  article,  which  appeared  in  1879, 

139 


140 


AFTER-TREATMENT    OP    SURGICAL    PATIENTS 


is  probably  the  most  comprehensive  work  we  have  on  the  clinical 
manifestations  of  this  malady. 

The  condition  occurs  most  frequently  following  fractures  and 
crushing  injuries  to  the  long  bones,  particularly  those  of  the  lower 
extremities.  Operations  on  joints,  surgical  interference  involving 
bone  or  even  the  forcible  straightening  of  a  contracted  limb  or  of 
ankylosed  joints,  result  not  infrequently  in  fatal  fat  embolism.  It  is 
fair  to  assume,  and  the  assumption  is  borne  out  by  the  literature,  that 
this  accident  occurs  only  where  fat  is  in  close  proximity  to  the  lesion ; 
force  sufficient  to  propel  the  fat  into  an  open  blood  vessel,  being  ex- 


Fig    22. — Fat  embolism  of  lung  following  multiple  fractures.      (After  Aschoff.) 


erted.  It  therefore  follows  that  contusions  of  the  panniculus  adipo- 
sus,  hemorrhage  into  or  rupture  of  the  liver  or  osteo-myelitis  pre- 
dispose to  this  malady. 

Patients  between  thirty  and  forty  years  of  age,  form  the  bulk  of 
those  afflicted,  while  il  is  least  common  in  children.  This  can  be 
very  properly  ascribed  to  the  fact  that  fractures  occur  more  often 
during  this  period  of  life  in  the  former,  while  the  medulla  of  the 
bone  in  the  Latter  contains  but  little  fat.  As  to  the  frequency  of 
fatal  fat  embolism,  it  should  be  stated  that  il  occurs  more  often  than 


FAT    EMBOLISM  141 

was  formerly  supposed,  though  owing  to  the  insufficiency  of  records 
it  is  hardly  possible  to  estimate  as  yet  the  mortality  rate.14  Meet13 
collected  113  cases  of  fatal  embolism  but  in  only  11  of  this  number 
could  he  be  certain  that  fat  was  the  causative  factor.  To  these  are 
added  two  more  cases  which  came  tinder  his  own  observation. 
Beitzke16  reports  a  ease  of  fatal  fat  embolism  occurring  within  a  few 
hours  following  a  slight  contusion  to  the  leg  stump,  the  operation 
having  been  performed  a  year  before.  Wahncan,17  Colley18  and  Au- 
reus19 each  report  a  case  in  which  fatal  embolism  occurred  following 
brisement  force  which  was  being  employed  in  an  effort  to  straighten 
contracted  limbs  due  to  ankylosed  joints.  Schanz20  records  a  case 
in  which  fat  emboli  produced  death  following  an  operation  which 
involved  osseous  tissue.  Byerson  reports  four  fatal  cases  due  to 
this  accident,  two  to  three  days  following  operation.  In  one  case 
operation  was  performed  in  order  to  correct  the  deformity  caused  by 
a  Pott's  fracture  one  week  old.  Embolism  followed  after  twenty- 
four  hours  and  death  within  forty-eight  hours.  In  another  case  fol- 
lowing an  Albee  operation  for  severe  paralytic  scoliosis  in  a  boy 
eight  years  old,  fat  embolism  occurred  in  three  hours  followed  by 
death  after  forty-eight  hours.  As  a  result  of  foot  drop,  due  to  pol- 
iomyelitis an  operation  was  undertaken  to  correct  the  deformity  in 
another  case  which  developed  fatal  fat  embolism  twenty-four  hours 
later. 

The  last  case  was  a  baby  eight  months  old,  operated  for  congeni- 
tal club  feet,  the  plantar  fascia  and  Achilles  tendon  above  being  sev- 
ered. The  baby  developed  symptoms  of  fat  embolism  after  twenty- 
four  hours  and  died  during  the  following  day. 

By  far  the  greatest  number  of  contributions  to  this  subject  are  de- 
voted to  experimental  studies  and  to  the  pathology,21  all  seeming  to 
agree  that  the  globules  of  fat  after  becoming  established  in  the  blood 
stream  first  lodge  in  the  capillaries  of  the  lungs.  If  the  quantity  of 
fat  is  of  sufficient  amount,  severe  symptoms  will  intervene,  resulting 
very  probably  in  death.  If  the  patient  survives  the  effects  of  the 
pulmonary  complication  and  the  heart's  action  is  sustained,  the  fat 
globules  will  be  forced  from  the  lungs  into  the  left  heart  and  hence 
into  the  general  circulation.  From  this  they  will  be  removed  by  the 
liver  and  kidneys,  and  unfortunately  the  brain  and  cord,  and  less 
frequently  by  the  other  various  organs.  Petechial  hemorrhages  may 
appear  in  the  skin  while  at  times  ecchyinosis  may  be  seen  on  the  mu- 
cous membranes  and  in  the  conjunctiva.  In  the  experimental  cases 
where  fat  embolism  was  produced,  Sehriba  found  the  following  lesions : 
' '  The  liver  was  markedly  congested  with  venous  blood,  fat  cells  being 


142  AFTER-TREATMENT    OF    .SURGICAL   PATIENTS 

found  throughout  the  parenchyma  along  the  periphery  of,  and  even 
within,  the  acini.  The  kidneys  showed  an  abundance  of  fat,  the 
glomeruli  particularly  were  loaded  with  fat  globules  and  many  ec- 
chymotic  areas  presented  beneath  the  capsule.  The  brain  and  cord 
especially  were  the  seat  of  most  interesting  findings.  The  coverings  of 
these  organs  were  congested  with  black  venous  blood,  while  the  arteries 
here  and  there  were  free  from  this  fluid.  However,  a  cross  section  of 
the  perivascular  spaces  showed  them  loaded  with  red  blood  corpus- 
cles. In  some  of  the  cases  the  brains  were  only  edematous  but  in  a 
few  the  ventricles  contained  serosanguinous  fluid,  while  in  others 
there  were  found  areas  of  softening.  Such  organs  as  the  heart,  stom- 
ach, intestines,  bladder,  muscles  and  even  the  skin  were  found  to  con- 
tain fat  emboli  in  a  number  of  other  case-,.  The  retina  and  especially 
the  chorioid  were  often  involved." 

Hamig22  reported  five  fatal  cases  of  fat  embolism  of  the  brain.  At 
autopsy  many  small  ecchymotic  areas  were  revealed  in  the  gray  and 
white  matter,  in  the  pons,  medulla,  and  even  the  central  ganglia;  par- 
ticularly in  one  case  were  the  dura  and  pia  congested  and  edematous. 

The  clinical  picture  in  fat  embolism  is  fairly  well  defined.  The 
severity  of  the  symptoms,  however,  depends  upon  the  organ  or  num- 
ber of  organs  involved.  Payr23  recognized  two  varieties,  one  the  re- 
spiratory and  the  other,  the  cerebral.  In  a  given  ease  the  most  prom- 
inent symptom  would  determine  to  which  variety  it  belonged.  Ac- 
cording to  some  observers  there  is  usually  an  incubation  period  of 
from  twenty-four  to  thirty-six  hours  following  the  operation  or  ac- 
cident.14 In  very  severe  crushing  injuries  this  period  may  be  re- 
duced to  as  low  as  three  hours  as  in  the  ease  reported  by  Beit/ke. 
Death  itself  has  occurred  within  this  time,  though  cases  are  reported 
in  which  it  occurred  as  late  as  the  eleventh  day.-4 

The  fat.  as  stated  above,  lodges  in  the  lungs  first.  This  is  followed 
by  difficult  respiration,  not  a  true  dyspnea  but  rather  an  air  hunger; 
there  is  pallor  followed  by  cyanosis  and  failure  of  the  circulation 
with  physical  signs  of  pulmonary  edema,  and  the  frequent  expectora- 
tion of  frothy,  blood-stained  mucus.  The  state  of  affairs  continues 
to  increase  in  severity  as  the  lungs  gel  more  and  more  edematous  and 
the  heart  weakens  correspondingly.  The  milder  cases  will  probably 
only  show  an  air  hunger  recovering  before  further  pulmonary  symp- 
toms develop.  The  temperature  may  go  as  high  as  106:  to  107°. 
Fat  may  appear  in  the  sputum  and  in  NO  per  cent  of  the  cases,  in  the 
urine,  according  to  the  authors  who  have  reported  the  urinary  find- 
ings. 


FAT    EMBOLISM  143 

As  it  would  be  naturally  supposed  the  cerebral  type  is  of  less  fre- 
quent occurrence.  The  entrance  of  the  fat  into  the  cerebral  circula- 
tion is  marked  by  nausea  and  vomiting,  followed  by  delirium,  som- 
nolence and  finally  coma,  hemorrhage,  and  thrombosis.  Localized 
paralysis,  trismus,  and  convulsions  were  noted  in  some  of  Hamig's 
cases,  and  Schanz  reports  one  instance  of  hemiplegia.  The  respira- 
tions are  usually  stertorous.  The  temperature  uncomplicated  by 
other  conditions  is  normal  or  subnormal,  and  is  associated  with  a 
rapid  weak  pulse. 

Unfortunately  there  is  no  specific  remedy  for  this  condition.  Ac- 
cording to  many  observers  a  considerable  decrease  in  the  number  of 
instances  can  be  obtained  by  bearing  in  mind  the  likelihood  of  this 
accident  and  giving  careful  attention  to  the  prevention.  Burger25  who 
has  studied  this  phase  of  the  disease  on  the  battle  fields  of  Europe, 
during  the  last  war,  states  that  the  tourniquet  is  probably  the 
best  means  we  have  of  warding  off  fat  embolism.  He  advises  its  ap- 
plication in  all  cases  of  fracture,  severe  crushing  injuries  of  the 
limbs,  or  general  contusions  to  the  bones  in  those  weakened  from  dis- 
ease or  in  the  aged.  In  very  severe  cases  especially  with  crushing  in- 
juries of  the  pelvis,  he  uses  Monberg's  constriction  at  the  waist  line 
for  at  least  half  an  hour ;  at  the  end  of  which  time  it  is  gradually 
loosened.  Another  precaution  is  to  avoid  the  moving  of  such  pa- 
tients to  very  great  distances,  as  this  particularly  predisposes  to  the 
malady.  Premature  massage  or  even  the  handling  of  the  patient  or 
unnecessary  disturbance  of  any  kind  may  end  in  dire  results. 

Extensive  laboratory  experimentation  on  dogs  and  rabbits  by  Ry- 
erson  has  shown  that  fractures  and  contusions  of  the  bones  cause 
much  more  embolism  than  does  the  performance  of  a  typical  Albee 
bone  transplant  to  the  spine,  for  instance.  However,  the  use  of  the 
chisel  and  mallet  in  the  performance  of  this  operation  is  far  more 
dangerous  than  the  motor  saw.  The  experiments  also  showed  fatty 
embolism  is  markedly  decreased  by  the  use  of  the  tourniquet  follow- 
ing all  kinds  of  traumatism.  Apparently  all  authorities  are  in  ac- 
cord with  this  view,  but  up  to  the  present  time  it  has  not  been  used 
as  a  routine  measure  by  any  one  man. 

If  the  accident  occurs  regardless  of  the  above  efforts,  emergency 
medical  measures  as  recorded  for  pulmonary  embolism  should  be  ap- 
plied here.  Protracted  absolute  rest  of  the  affected  part  must  be 
particularly  insisted  upon,  inasmuch  as  additional  quantities  of  fat 
may  continue  to  enter  the  circulation.  The  heart's  action  should  be 
sustained  with  strophanthus  or  digitalis  during  its  attempt  to  force 


144  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

the  fat  globules  through  the  pulmonary  capillaries  iu  an  effort  to  re- 
lieve the  embarrassed  respiration.  It  is  a  question  whether  the  class 
of  remedies  exemplified  by  ainyl  nitrite  should  be  used  to  force  a 
dilatation  of  the  peripheral  and  pulmonary  vessels  since  this  addi- 
tional strain  may  be  too  great  for  the  already  overloaded  heart. 

Later,  while  the  oil  is  being  disposed  of  by  the  liver  and  kidneys, 
assisted  by  the  process  of  oxidation  and  of  saponification  effected  by 
a  ferment  in  the  blood  plasma  and  b}'  the  metabolic  and  phagocytic 
activities  of  the  leucocytes,  the  medical  treatment  can  be  symptom- 
atic only.  Further  treatment  as  proposed  in  the  recent  literature  is 
apparently  not  on  a  well-defined  basis.  Czerny26  in  an  attempt  to 
assist  the  blood  in  forming  a  soluble  soap  injected  2  per  cent  sodium 
rail  innate,  but  the  method  received  little  support.  Schanz  injects 
subcutaneously  a  liter  of  normal  salt  solution  at  the  first  sign  of 
trouble ;  various  parts  of  the  body  being  utilized  for  this  purpose  in 
order,  he  thinks,  to  more  promptly  and  effectually  accomplish  the 
desired  dilatation  and  flushing  out  of  the  capillaries  involved.  He 
reports  ten  cases  of  fat  embolism  occurring  after  operation  on  the 
bones  with  the  loss  of  only  one  patient  after  employing  this  method. 
While  others,  notably  Beitzke,  do  not  sanction  this  treatment,  I 
feel  that  it  should  be  given  a  trial  so  long  at  least  as  the  solution  is 
qo1  given  intravenously.     It  is  also  advocated  by  Gangele. 

Wilms-7  drained  the  thoracic  duct  for  four  days  with  recovery  of 
the  patient.  Tanton28  recommends  this  procedure  also.  They  base 
this  action  mi  the  theory  that  the  fat  is  carried  principally  by  the 
lymphatic  system  rather  than  by  the  venous.  Though  the  fat  con- 
tained in  the  thoracic  duct  may  be  the  metaphorical  last  straw, 
Wilms'  method  receives  but  little  support. 

Riener29  advises  draining  off  the  venous  blood  with  its  admixture 
of  fat  by  means  of  a  cannula  inserted  into  the  saphenous  vein  and 
hence  into  the  femoral  vein,  lie  ■siy^  that  the  amount  of  fat  neces- 
sary to  cause  the  initial  symptoms  sufficient  for  diagnosis,  does  not 
always  produce  death,  the  fatal  dose  having  not  as  yet  passed  the 
Poupart's  ligament.  This  method  is  approved  by  other  observers. 
Tanton  would  open  up  the  area  of  injury  and  remove  the  accumu- 
lated hi 1  and  t'at.  using  drainage  or  tamponade,  a  procedure  hav- 
ing many  advocates. 

Venesection  relieves  the  heart  which  is  beating  against  the  fat  em- 
boli in  the  greater  circulation  and  should  lie  employed  in  suitable 
cases.  If  brain  pressure  symptoms  develop  from  the  venous  stasis 
or  hydrocephalus,  leeches  to  the  mastoid  may  be  of  aid  in  diverting 
the  fluid.     Lumbar  puncture  may  be  applied  with  caution. 


FAT   EMBOLISM  145 

After  the  recovery  from  the  immediate  effects  of  the  accident,  I 
would  naturally  expect  a  longer  convalescence  of  the  patient  than 
without  this  complication.  Dizziness,  fatigue,  dyspnea,  heart  dis- 
turbances or  even  mental  depression  may  be  present  for  an  indefinite 
time.  If  such  are  prominent,  however,  lumbar  puncture  supple- 
mented by  hot  foot  baths,  air  and  sun  baths,  and  revulsive  measures 
should  be  carried  out.  The  patient  must  be  warned  against  over-ex- 
ertions either  mental  or  physical.  If  possible,  give  him  light  work 
and  let  his  ordinary  occupation  be  gradually  resumed. 

Bissell30  writes:  "It  would  seem  reasonable  to  conclude  that  in 
persons  with  broken  bones  there  is  frequently  a  remarkable  amount 
of  fat  in  the  blood  stream,  and  almost  incredible  amounts  of  fat  may 
be  in  the  blood  and  yet  not  kill.  Further,  it  might  be  assumed  that 
the  amounts  of  fat  free  in  the  blood  stream  of  persons  with  broken 
bones  vary  from  time  to  time,  and  it  is  very  essential  for  any  inter- 
pretation of  these  results  to  remember  that  in  no  instance  was  the 
whole  blood  examined;  that  other  similar  amounts  from  the  same 
patients  (or  dead  bodies)  might  have  shown  a  fat  content  either 
greater  or  less,  since  the  fat  is  not  emulsified  but  is  in  motion  as  free 
fat  droplets,  and  no  doubt  these  vary  from  time  to  time  in  their 
number  and  size  as  well  as  in  their  distribution,  the  blood  in  some 
places  perhaps  being  rich  in  fat  and  in  others  poor  or  with  no  fat  as 
emboli." 

BibliogTaphy 

^Fromberg:  Mitt.  a.  Grenzgeb.  d.  Med.  u.  Chir.,  1913,  xxvi,  23. 

sMagendie:  Jour.  de.  physiol.,  1821,  i,  37. 

s  Weber:      Deutsch.   Klin.,    1864,   p.  466.     Pitha  und   Billroth:      Handbuch   der 
Chirurgie,  i,  pp.  84,  85,  95,  98. 

^Schwick:     De  ernbol.  adipe  liqu.  effecta,  Dissert.,  Bonnse,   1864. 

sVirchow:     Dessen  Arch.,  v,  388. 

eMuller:     Erkrankungen  der  Choriodea,  Wiirzburg  med.  Ztsehr.,  i,  1860. 

^Zenker:     Beitrage  z.  norm.  u.  path.  Anatomie  der  Lrmgen,  Dresden,  1862,  p. 
31. 

s  Wagner:     Arch.  d.  Heilkd.,  3  Jahrg.,  1862,  p.  241. 

silohlbeek:     Ein  Beitrag  zur  Lehre  vonder  Embolie,  etc.,  Dorpat,  1863,  Dissert. 
loBergmann:     Die  Lehre  der  Fettembolie,  Berl.  klin.  Wchnschr.,  1873,  No.  33. 
nBusch:     Leber  Fettembolie,  Virchows  Arch.  f.  path.  Anat.,  1866,  xxxv,  19  Kap. 
i2Flournoy:     Contributions  a  1 'etude  de  L 'embolie  graisseuse.     Diss.,  Stratburg, 

1878. 
isSchriba:     Untersuch.  iiber  die  Fatt  Embolism,  Leipzig,  1879. 
i<Ryerson :      Jour.  Am.  Med.  Assn.,  August,   1916. 
isMeet:     Beitr.  klin  Chir.,  viii. 

isBeitzke:     Eev.  med.  de  la  Suisse  romande,  1912,  xxxii,  501. 
^Wahncan:     Inaug.  Dissert.,  Halle,  1886. 
isColley:     Deutsch  ztsehr.  f.  Chir.,  1893,  xxxvi. 
lfAhrens:     Beitr.  klin.  Chir.,  xiv. 
soSchanz:     Zentralbl.  f.  Chir.,  Jan.  1,  1910. 
-iFrazier:     Keen's  Surgery,  1906,  i,  464. 
22Hamig:     Beitr.  klin.  Chir.,  xxviii. 


146 


AFTER-TREATMENT    OF    SURGICAL   PATIENTS 


-'sPayr:     Munch,  med.  Wchnschr.,  1898,  No.  28. 

24g.chriba :     Quoted  bv  Frazier,  Keen  's  Surgery. 

25Burger:  Med.  Klin.,  Sept.  5,  1915,  No.  36. 

2«Czerny:  Quoted  by  Warthin. 

27\Vilms:  Sem.  med.,  1910,  xxx. 

28Tanton:  Jour,  de  Chir.,  March,  1914,  xii,  No.  3. 

2£-Eiener:  Centralbl.  f.  Chir.,  1907. 

soBissell:  Jour.  Am.  Med.  Assn.,  Dec.  23,  1916. 


CHAPTER  XVIII 

HEAT  STROKE 
By  0.  F.  McKittrick,  St.  Louis.  Mo. 

In  addition  to  the  ordinary  dangers  attendant  upon  an  operation, 
there  is  another  which  occurs  in  summer  during  or  immediately  fol- 
lowing a  heat  wave.  This  condition  has  been  considered  "heat 
stroke"  by  Gibson  who  apparently  was  the  first  to  recognize  the 
malady  as  an  important  postoperative  complication.  This  author  re- 
ported two  cases  in  1900.  Shortly  thereafter  Johnson  and  Becker  re- 
ported three  and  one  cases,  respectively.  Since  this  time  less  than 
half  a  dozen  more  cases  had  been  brought  to  the  attention  of  the 
medical  profession  when  Moschcowitz1  in  1916  added  five  more  to 
the  list. 

This  complication  according  to  Moschcowitz  is  apt  to  follow  a  long- 
continued  term  of  fairly  high  temperature  with  a  high  percentage  of 
humidity  and  no  breeze,  rather  than  an  exceedingly  high  tempera- 
ture with  a  good  breeze.  He  has  noticed  that  the  longer  the  former 
atmospheric  state  exists  the  greater  will  be  the  number  of  cases  re- 
corded. 

The  condition  is  considered  one  of  heat  stroke  since  the  patients 
present  symptoms,  more  or  less  like  those  of  sun  stroke ;  though  of 
the  cases  recorded  only  one  was  in  any  way  directly  exposed  to  the 
rays  of  the  sun.  In  every  instance  except  this  one,  all  the  patients 
had  been  sick  either  at  home  or  in  the  hospital  prior  to  the  operation. 

As  to  when  the  onset  of  symptoms  occurred,  nothing  as  yet  can  be 
said  definitely,  since  all  the  patients  were  operated  on  under  general 
anesthesia.  In  some  of  the  cases  symptoms  of  this  malady  had  begun 
to  assert  themselves  before  the  patient  was  entirely  awake  from  the 
anesthetic  while  in  others  more  than  twenty-four  hours  had  elapsed. 

One  of  the  patients,  a  boy,  as  reported  by  Moschcowitz  was  operated 
for  appendicitis.  Some  pus  was  found  and  the  abdomen  was  drained. 
Following  partial  recovery  from  the  anesthetic  the  child  was  restless 
and  noisy.  The  temperature  started  to  rise  and  five  and  one-half  hours 
after  operation  it  had  reached  105.6 c.  The  exposed  parts  of  the  body 
where  then  sponged  with  ice  water  and  ice  was  put  on  the  head.  In 
spite  of  this  the  temperature  continued  to  go  higher  and  thirteen  and 
one-half  hours  after  operation  it  had  reached  109°.    Four  hours  later 

147 


148  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

the  patient  had  a  convulsion  which  lasted  twenty  minutes.  One  hour 
later  another  convulsion  occurred  followed  by  death  twenty  and  one- 
half  hours  after  operation.  The  temperature  never  fell  below  105°, 
and  no  reason,  outside  that  given,  could  be  assigned  as  the  cause  of 
death. 

In  another  case  reported  by  Gibson2  the  patient  was  doing  nicely 
following  an  operation  for  acute  appendicitis,  until  the  afternoon 
of  the  following  day.  At  this  time  the  temperature  had  gone  to  104°, 
the  pulse  to  148,  and  was  very  poor.  The  face  became  ashen  gray, 
the  nose  pinched,  and  the  skin  hot  and  dry ;  there  was  restlessness 
and  delirium.  As  soon  as  the  condition  was  diagnosed,  alcohol 
sponge  baths  reduced  the  temperature  in  a  short  time  and  the  pa- 
tient went  to  sleep.  The  patient  soon  after  recovered  without  any 
apparent  ill  effects. 

The  condition  is  a  serious  one  and  no  doubt  has  resulted  in  many 
deaths  attributed  to  other  causes.  In  many  hospitals  the  patient  is 
completely  wrapped  in  blankets  during  the  operation  or  the  trans- 
portation to  and  from  the  operating  room  and  finally  so  enveloped  in 
bed  as  to  prevent  chilling  and  ultimately  pneumonia.  This  habit  dur- 
ing hot  weather  is  no  doubt  very  likely  to  lead  to  overheating  with 
the  appearance  of  this  dangerous  complication. 

The  treatment  concerns  itself  with  the  prevention  of  any  undue 
heating  of  the  patient.  Even  in  the  operating  room  whenever  in< 
cated  an  ice  cap  should  be  placed  on  the  head  of  the  patient  as  has 
been  already  suggested  by  others.3  The  clothing  should  be  very  light 
and  the  covering  cool  and  airy.  Cool  drinks  should  be  given  before 
operation  also  ice  by  mouth  as  soon  as  the  patient  awakes  from  the 
anesthetic.  Electric  or  manual  fanning  could  be  kept  up  if  the  pa- 
tient is  in  need  of  such  treatment. 

If,  in  spite  of  such  preventive  treatment,  the  patient  develops  a 
high  temperature  with  the  attendant  symptoms  of  heat  stroke,  fre- 
quent alcohol  or  cold  sponging  of  the  whole  body  must  be  instituted 
and  cold  water  proctoclysis  be  started.  If  this  is  not  borne  by  the 
patient  colonic  flushings  with  ice  water  should  be  carried  out. 

If  the  hyperpyrexia  still  continues  regardless  of  these  measures,  the 
patient  is  covered  with  a  cold  wet  sheet  upon  which  is  laid  many 
small  pieces  of  ice.  Ice  water  now  is  allowed  to  drip  for  twenty  to 
thirty  minutes  on  him  from  drippers  held  8  to  10  feet  above  the 
bed.  A  fine  stream  of  ice  water  as  suggested  by  Chandler4  is  poured 
on  the  head  for  one  or  two  minutes  at  a  time.  When  the  temperature 
has  dropped  to  104°  as  evidenced  by  a  thermometer  which  has  been 
kept  in  the  rectum  throughout  the  whole  procedure,  these  heroic 


HEAT    STROKE  149 

measures  are  at  once  discontinued.  The  patient  is  now  wrapped  in 
a  blanket  and  hot-water  bottles  applied  to  the  limbs  and  trunk.  Un- 
der no  circumstances  give  an  antipyretic  but  stimulate  the  heart. 
The  drugs  which  are  best  for  this  purpose  can  be  selected  as  the  oc- 
casion arises.  If  breathing  stops,  artificial  respiration  must  be  car- 
ried out  for  at  least  one  hour  before  the  patient  is  given  up. 
Alcohol  is  especially  indicated  where  there  has  been  excessive  indul- 
gence during  health. 

Heat  Prostration. — Instead  of  the  high  temperature,  the  hot  skin 
and  general  symptoms  of  heat  stroke,  the  patient  may  present  the 
picture  of  syncope,  with  shallow  labored  respirations,  dilated  pupils, 
cold,  clammy  skin,  a  subnormal  temperature  and  a  small,  soft  pulse. 
This  condition  is  brought  on  by  exactly  the  same  factors  which  cause 
heat  stroke.  It  is  called,  however,  "heat  prostration."  The  treat- 
ment is  directly  opposite  that  described  for  the  complication  above. 

The  foot  of  the  bed  should  be  elevated  at  once,  the  patient  covered 
with  blankets  and  surrounded  with  hot-water  bottles.  Subcutaneous 
salt  solution  is  to  be  continuously  kept  up  until  the  patient  revives; 
in  addition  proctoclysis  warm  plain  tap  water  is  in  order.  If  the 
blood  lakes  as  some  observers  have  noted,  venesection  should  be  done 
and  blood  transfusion  carried  out  if  a  suitable  donor  can  be  had  on 
short  notice.  Here,  as  in  the  condition  above  mentioned,  careful  at- 
tention must  be  given  the  heart. 

Bibliography 

JMoscheowitz :     Surg.,  Gynee.  and.  Obst.,  Oct.,  1916. 
^Gibson:     Med.  News,  1900,  Dec,  8,  p.  883. 
sCrandon  and  Ehrenfried:     Surgical  After-treatment,   1912. 
iChandler:     Med.  Eec,  New  York,  1897. 


CHAPTER  XIX 

POSTOPERATIVE   BURNS 
By  Willard  Bartlett,  St.  Louis,  Mo. 

The  consideration  of  postoperative  burns  would  furnish  an  unnec- 
essary and  even  obsolete  chapter  in  the  annals  of  after-treatment  if 
human  ingenuity  could  reach  that  degree  of  perfection  in  which  no 
mistakes  are  made  and  all  little  preventive  acts  are  remembered ; 
since  this  complication  arises  only  when  some  one  connected  with  the 
operation  or  postoperative  care,  has  blundered.  The  occurrence, 
therefore,  of  this  accident  is  always  a  matter  of  most  serious  regret, 
one  always  causing  marked  annoyance  to  the  patient  and  in  many  in- 
stances chagrin  or  even  medico-legal  worries  for  the  physician. 

The  general  subject  of  burns  can  not  be  treated  in  a  work  of  this 
kind,  hence  only  those  occurring  as  a  postoperative  complication  can 
be  discussed.  Here  follows  a  list  of  the  varieties  with  which  we  have 
been  confronted,  by  no  means  all  of  them  caused  by  heat  alone. 

Depilatory  Burns. — One  of  the  unlooked  for  accidents  associated 
with  an  operative  procedure  at  times  occurs  after  the  use  of  depila- 
tory chemicals  in  hastily  preparing  a  hairy  field  for  operation.  For- 
tunately such  agents  are  not  in  very  common  use  at  the  present  time, 
else  such  lesions  would  no  doubt  be  more  commonly  seen. 

Depilatory  burns  may  be  serious  if  the  chemical  be  confined  on  the 
skin  for  any  length  of  time.  I  once  had  to  prepare  a  patient  hur- 
riedly upon  the  table,  for  a  lengthy  abdominal  operation,  with  the 
result  that  a  small  amount  of  the  calcium  sulphide,  which  we  were 
using  ran  over  the  patient's  side  and  was  confined  between  her  back 
and  the  sheet  upon  which  she  lay.  An  extensive  and  serious  burn 
resulted  which  had  not  healed  when  she  left  the  hospital,  twelve 
days  later,  and  of  which  she  complained  more  than  she  did  of  the 
effects  of  the  operation  which  had  been  performed.  It  is  questionable 
whether  depilatory  agents  should  ever  be  used,  since  their  action  is 
at  best  uncertain,  and  unless  accurately  timed,  will  destroy  the  epi- 
dermis along  with  the  hair  which  alone  it  is  intended  to  remove. 

Iodine  Burns. — Another  cause  for  this  complication  is  the  use 
of  that  efficacious,  yet  dangerous  chemical,  iodine,  which  is  now  so 
commonly  employed  for  skin  disinfection.  This  agent  acts  differently 
on  the  skin  of  different  patients;  some  seem  to  bear  it  with  impunity, 

150 


POSTOPERATIVE   BURNS  151 

while  others  acquire  burns  wherever  it  is  applied  and  many  of  them 
require  from  one  to  two  weeks  careful  treatment  before  the  skin  is 
normal  again.  If  one  hopes  to  use  iodine  successfully  he  must  avoid 
applying  it  to  skin  which  has  been  recently  moistened.  If  the  skin 
must  be  shaved  immediately  before  its  application,  it  is  imperative 
that  this  be  a  dry  shave  with  benzine  or  some  other  nonaqueous 
fluid.  If  this  is  impossible,  alcohol  and  ether  may  be  employed  to 
sufficiently  dry  the  skin  surface  or  else  one  must  wait  until  it  becomes 
dry  of  its  own  accord.  I  am  confident  that  many  iodine  burns  could 
have  been  avoided  by  the  careful  observance  of  this  well-known  fact 
which  was  embodied  in  the  earliest  writings  on  this  subject.  The  ex- 
cess of  iodine  which  remains  around  the  edge  of  an  area  prepared  for 
operation,  or  that  remaining  after  the  operation  is  completed,  should 
be  carefully  removed  with  alcohol.  Some  hospitals  employ  sponges 
saturated  with  starch  water  for  this  purpose,  a  practice  which  can 
not  be  too  highly  recommended.  The  starch,  as  is  perfectly  well 
known,  completely  alters  the  chemical  composition  of  the  drug:  this 
aids  materially  in  preventing  the  unpleasant  after  effects  of  an  ex- 
cess of  this  irritating  substance  on  the  skin. 

Ether  Burns. — During  the  operative  procedure  burns  may  also  oc- 
cur from  ether  which  has  been  spilled.  In  fact,  burns  about  the  face 
and  neck  are  very  common  in  the  hands  of  anesthetists  who  persist 
in  using  an  impervious  cover  of  rubber,  gutta  percha,  etc.,  for  the 
eyes  and  adjacent  exposed  skin.  As  mentioned  in  the  discussion  on 
ether  conjunctivitis,  this  fluid  or  even  its  vapor  when  confined  under 
impervious  material  creates  a  burn  which  is  exactly  limited  to  the  ex- 
tent of  the  skin  covering  employed. 

Hot-water  Bottles. — Perhaps  the  most  common  of  all  postoperative 
burns  result  from  the  contact  with  liot-wcuter  hottles.  These  should,  of 
course,  always  be  tested  by  a  thermometer,  but  are  probably  very 
rarely  so  tested.  In  consequence  the  nurse's  hand,  being  accustomed 
to  a  degree  of  heat  that  will  astonish  any  man.  establishes  a  standard 
for  her  patient  by  guesswork  and  then  she  applies  to  a  surface 
which  is  much  more  sensitive  than  the  hand,  a  degree  of  heat  which 
it  can  not  at  all  tolerate  and  later  is  at  a  total  loss  to  account  for 
the  burns  which  constitute  one  of  our  most  prolific  sources  of 
medico-legal  complications. 

Glass  bottles  should  never  be  the  medium  of  applying  heat  to  a 
patient,  since  their  very  nature  makes  equal  pressure  everywhere 
upon  the  skin  an  absolute  impossibility,  and  heat  applied  with  con- 
siderable pressure  upon  one  point  is  more  certain  to  damage  the 
tissues  than  if  the  same  degree  be  applied  in  the  form  of  a  yielding 


152  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

rubber  container  which  molds  itself  readily  to  the  outline  of  the  part 
with  more  or  less  equal  pressure  everywhere.  It  is  doubtful  whether 
heat  should  be  applied  at  all.  where  it  can  be  avoided,  to  a  patient 
who  is  still  unconscious  from  the  anesthetic  and  thus  unable  to  con- 
vey to  his  attendant  any  impression  of  the  sensations  produced.  The 
application  of  heat  through  the  medium  of  hot  water  has  one  dis- 
agreeable feature  no  matter  what  form  of  container  is  used;  namely, 
a  leak  is  very  likely  with  the  consequence  that  the  patient  lies  in  a 
puddle  until  the  accident  is  discovered  and  in  some  instances  there- 
after for  an  indefinite  time.  The  electric  foot  warmer  now  so  com- 
monly used  can  be  adjusted  to  suit  the  requirements  of  the  case,  and 
since  it  works  at  different  temperatures  easily  predetermined  it  is  by 
all  means  to  be  recommended. 

Enemas. — Burns  from  enemas  are  no  doubt  very  rare.  I  happen 
to  know  of  one  instance,  however,  in  which  a  hospital  was  sued  for 
malpractice  by  a  patient  who  claimed  to  have  suffered  from  an  acci- 
dent of  this  nature.  While  she  was  unconscious  after  the  anesthesia 
a  douche  point  had  been  inserted  in  the  rectum  and  connected  through 
a  partially  opened  stopcock  with  a  can  containing  water  hot  enough 
to  reach  the  rectum  drop  by  drop  and  still  be  quite  warm.  The  nurse 
left  the  room  and  the  patient  moved  in  such  a  way  as  to  open  the 
stopcock,  with  the  result  that  there  was  a  free  flow  of  water  so  hot 
that  the  mucous  membrane  and  skin  of  the  anal  region  were  destroyed 
this  being  followed  by  extensive  scar  formation. 

Burns  of  the  mucous  membranes  of  the  mouth  occur  from  ingestion 
of  too  hot  liquids,  but  are  of  such  a  trifling  character  as  to  be  prac- 
tically negligible. 

The  electric  light  treatment  for  open  wounds  which  has  come  so 
strongly  into  vogue  in  the  recent  past  has  contributed  the  most  mod- 
ern chapter  t<>  this  subject.  To  be  thoroughly  efficacious  the  light 
built  must  come  within  a  few  inches  of  the  region  to  be  treated,  hence 
it  is  readily  understandable  that  the  sudden  movement  of  a  sleeping 

patient  or  ind 1.  of  one  awake  for  that  matter,  may  bring  the  glass 

bulb  into  immediate  contact  with  the  body  with  the  most  disastrous 
consequences.  In  one  instance  where  the  bulb  was  suspended  in  ray 
practice  immediately  over  a  Large  suppurating  appendix  wound,  a 
faulty  connection  gave  way.  the  incandescent  bulb  fell  onto  the  pa- 
tient who  happened  to  lie  asleep,  and  before  it  was  removed,  a  sec 
degree  burn  of  considerable  extent  ensued  with  the  result  that  wound 
healing  was  distinctly  complicated  and  lengthened  thereby. 

In  other  instances  where  heat  is  maintained  by  a  number  of  elec- 
tric bulbs  arranged  as  in  the  Gellhorn  apparatus,  or  hanging  sus- 


POSTOPERATIVE    BURNS  153 

pended  far  above  the  patient  aud  inclosed  with  him  in  a  specially  ar- 
ranged "burn  bed"  these  may  cause  superficial  burns  of  the  parts 
of  the  body  exposed.  In  such  beds  the  temperature  is  maintained  by 
covering  the  frame  which  supports  the  lights  with  blankets,  oil  cloth, 
or  other  materials.  The  degree  of  heat  desired  is  about  85°  C.  but 
occasionally  it  becomes  excessive,  and  although  the  patient  is  very 
uncomfortable,  complaint  and  examination  are  often  not  made  until 
damage  has  been  done.  I  have  seen  two  instances  in  which  super- 
ficial first  degree  burns  occurred  under  such  circumstances.  In  one, 
a  burn  of  the  skin  over  the  abdomen  appeared  in  a  woman  patient 
who  fell  asleep  and  the  nurse,  not  acquainted  with  the  efficient  ap- 
paratus for  developing  heat,  allowed  the  part  exposed  to  become  so 
injured  that  it  was  several  days  before  the  skin  assumed  its  normal 
appearance. 

In  the  other  instance  a  leg  having  been  amputated  for  indolent  ul- 
cer and  the  tissues  being  very  slow  to  heal  due  to  arteriosclerosis,  the 
patient  was  kept  in  bed  with  the  stump  and  lower  part  of  his  body 
kept  covered  by  a  frame  from  which  several  electric  light  bulbs  were 
swung  at  least  16  inches  high.  The  frame  was  in  turn  covered  by 
two  blankets,  the  upper  portion  of  the  body  being  outside  of  the  en- 
closed portion  of  the  bed.  Within  one-half  day  the  hyperemia  be- 
came so  extensive  and  the  pain  so  severe  that  it  was  deemed  advisa- 
ble to  discontinue  the  treatment.  The  skin  over  the  exposed  regions 
gave  all  the  signs  of  a  superficial  burn,  and  was  four  days  in  recover- 
ing from  the  effects  of  this  treatment. 

X-ray. — The  x-ray  is  another  factor  to  be  considered  in  the  etiol- 
ogy of  postoperative  burns.  So  often  is  this  method  of  treatment  in- 
stituted, particularly  after  operations  for  malignancy,  that  it  is  no 
more  than  natural  to  occasionally  expect  a  complication  of  this  sort. 
I  have  seen  one  or  two  such  instances,  though  the  condition  is  not  so 
common  as  one  would  expect  when  the  number  of  cases  so  treated  are 
considered.  Probably  this  is  clue  to  the  fact  that  the  nature  of  the 
treatment  itself  requires  more  expert  application  than  does  the  usual 
routine  after-care  and  is  therefore  handled  by  a  special  class  of  men 
skilled  in  their  individual  work.  Sajous1  in  discussing  the  subject 
says:  "Close  proximity  to  the  ray  by  either  covered  or  uncovered 
parts  results  either  in  superficial  or  deep  inflammation  of  the  skin. 
It  may  be  observed  a  few  hours  after  exposure  to  the  rays  or  may  be 
delayed  for  several  weeks.  This  form  of  burning  attacks  the  skin 
alone  in  some  instances,  while  in  others  the  deeper  structures,  as  the 
muscles,  tendons,  nerves,  and  bones  (periostitis  and  ostitis  resulting) 
are   involved.     The   effects   may  remain   for   days,   weeks,    or   even 


154  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

months  after  the  application.  The  x-ray  burns  are  supposed  by  some 
to  be  produced  by  the  action  of  the  ray  or  by  particles  of  aluminum 
or  platinum  reaching  and  being  deposited  in  the  tissues  by  others, 
and  by  yet  others  to  be  the  result  of  an  interference  with  the  nutri- 
tion of  the  part  by  the  induced  static  charges." 

The  effects  of  these  static  charges  can  be  absolutely  eliminated  ac- 
cording to  Sajous1  by  interposing  some  conducting  material,  one 
readily  penetrated  by  the  rays,  such  as  a  sheet  of  aluminum  or  gold 
leaf.  "As  an  added  precaution  we  have  found  it  extremely  valuable 
to  have  treatment  administered  by  an  experienced  roentgenologist, 
one  thoroughly  familiar  with  the  work  in  hand.  Such  men  inform  us 
that  it  is  not  so  much  in  protecting  the  parts  to  be  x-rayed  with  alum- 
inum as  the  giving  of  too  frequent  small  doses  or  a  too  long  exposure 
at  one  time." 

Ice. — The  application  of  ia  continuously  for  several  hours  may 
result  in  the  complete  destruction  of  skin  with  a  resulting  lesion  so 
similar  to  a  burn  that  for  all  practical  purposes  it  is  well  classed 
under  this  common  heading.  I  was  recently  shown  a  most  extensive 
burn  of  this  sort  by  a  colleague  at  the  Jewish  Hospital  of  this  city. 
During  the  course  of  a  pelvic  inflammatory  disease  an  ice  bag  had 
been  continuously  applied  for  many  hours  directly  upon  the  skin  of 
the  lower  abdomen  until  at  the  expiration  of  this  time  nutritional 
changes  had  commenced  which  finally  resulted  in  a  slough  equal  in 
size  to  the  bag  itself.  The  effect  of  ice  upon  the  tissues  is  very  rarely 
as  extensive  as  that  here  mentioned,  still  all  of  us  have  seen  a  red, 
tender  edematous  area  persist  for  many  hours  after  a  too  long  con- 
tinned  application  of  this  sort.  Treatment  in  this  instance  should 
be  preventive  in  nature,  the  rules  underlying  it  being  of  such  an  ex- 
ceedingly simple  nature  that  their  nonobservance  is  almost  inexcusa- 
ble. An  ice  bag  should  under  no  circumstances  be  applied  directly 
upon  the  skin,  but  should  have  one  or  two  layers  of  flannel  cloth  be- 
neath it;  even  then  no  ice  bag  should  remain  in  situ  for  more  than 
two  out  of  three  hours  at  a  time. 

Pathology  and  Morbid  Anatomy. — Prom  the  pathologic  stand- 
point, the  effect  on  bodily  tissues  of  various  caloric  agents  is 
essentially  the  same.  The  amount  and  severity  of  the  change  depends 
on  the  intensity  and  duration  of  the  agent,  the  extent  and  location  of 
the  involved  area,  ami  whether  the  normal  equilibrium  of  the  skin  is 
disturbed  by  local  infection  or  lowered  constitutional  resistance. 

It  is  customary  to  classify  burns  in  three  degrees.  First. — Char- 
acterized by  simple  erythema  and  destruction  of  only  the  superficial 
Layers  of  the  epithelium,  with   occasionally  some  slight  swelling  of 


POSTOPERATIVE    BURNS  155 

the  part.  Second. — In  this  class,  in  addition  to  the  above  there  is 
formation  of  bullae  or  blebs  filled  with  clear  serum;  and  considerable 
swelling.  In  neither  of  these  classes  are  the  deeper  crypts  of  epi- 
thelium destroyed,  and  regeneration  takes  place  with  little  or  no  scar 
formation. 

Third. — Typical  of  this  degree  is  the  carbonization  of  the  dermis 
and  deeper  structures  with  eschar  formation.  In  this  type  the  ne- 
crotic tissues  slough  off,  leaving  an  ulcerating  surface  which  slowly 
heals  by  granulation,  scar  formation,  and  cicatrization. 

Accompanying  the  above  changes  are  the  usual  manifestations  of 
inflammation  with  suppuration.  Suppuration  is  furthered  by  the 
formation  of  scabs. 

Because  of  the  excellent  culture  medium  afforded  by  the  abundant 
serous  exudate  and  autolyzed  necrotic  tissue,  infection  is  especially 
prone  to  occur,  which  not  only  retards  healing  but  seems  to  favor 
more  extensive  cicatrization  and  contractures. 

In  addition  to  these  local  changes,  certain  alterations  in  the  vis- 
cera and  serous  membranes  are  observed  in  patients  dead  of  exten- 
sive burns.  Bardeen2  reviewed  the  literature  on  this  subject  and  in 
addition  laid  especial  emphasis  on  edema  and  focal  necrosis  of  lymph- 
oid tissue  with  increased  cell  proliferation.  Cloudy  swelling  and 
parenchymatous  degeneration  of  the  liver  and  kidney,  enlargement 
of  the  spleen,  edema  of  the  lungs,  meningeal  and  general  visceral  con- 
gestion are  quite  constantly  found.  Recently  Weiskotten3  has  called 
attention  to  a  condition  of  edema  and  necrosis  of  adrenal  tissue 
which  he  believes  is  characteristic  of  burns. 

A  number  of  theories  have  been  advanced  in  explanation  of  these 
changes  which  are  discussed  in  full  by  Togt.4  It  is  probable  that 
hemolytic,  cytotoxic  and  neurotoxic  substances  are  formed  in  the 
burned  area  which  bring  about  the  visceral  and  blood  changes  as 
well  as  the  condition  of  shock  so  often  seen  following  even  compara- 
tively slight  burns.  There  is  considerable  disagreement  among  in- 
vestigators as  to  the  nature  and  action  of  these  substances.  (For 
fuller  discussion  see  AVells,  Chemical  Pathology.) 

Blood  changes  are  manifested  in  sluggish  circulation  and  assump- 
tion of  a  darker  purplish  color.  The  erythrocytes  are  increased 
two  to  four  million  in  fatal  and  one  to  two  million  in  nonfatal  cases. 
Fragmentation,  clumping,  and  distortion  of  the  red  cells  with  ten- 
dency to  thrombus  formation  occurs.  There  is  loss  of  water,  hemo- 
globinuria and  hematuria.  The  platelets  are  notably  increased  with 
marked  tendency  to  clot  on  part  of  the  blood.  In  fatal  cases  a  rapid 
leucocytosis   of   50,000   or   more,   and   in   the   nonfatal   of   30,000   to 


156  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

40,000,  is  found.5    Coincident  with  this  leucoeytosis  there  is  consider- 
able destruction  of  leucocytes. 

Burns  following  exposure  to  x-rays  differ  somewhat  in  their  path- 
ology from  burns  resulting  from  direct  contact  with  a  caloric  agent. 
Here  again  three  general  classes  may  be  distinguished :  First. — 
In  which  there  is  simple  erythema.  Second. — In  which  there  is  in- 
flammation with  loss  of  epithelium.  Third. — In  which  there  is  deep 
ulceration.  In  addition  to  these  more  or  less  external  manifestations, 
certain  changes  occur  in  internal  organs  directly  subjected  to  the 
rays,  characterized  by  destruction  of  the  parenchyma  with  increased 
connective  tissue  formation.  Such  changes  are  most  evident  a  wreek 
or  ten  days  following  exposure.  There  is  intracellular  edema,  and 
pyknosis  of  the  cells.  Cells  of  the  embryonal  type  are  most  easily 
affected. 

The  changes  in  the  skin  and  immediately  underlying  structures 
are  :6  rarefaction  of  the  superficial  layers  of  the  corium  with  in- 
creased density  in  the  deeper  layers ;  hyaline  degeneration  through- 
out the  corium ;  increase  in  elastic  tissue ;  vacuolation  and  hyaliniza- 
tion  of  smooth  muscle  fibers;  obliteration  of  lymphatic  spaces;  di- 
latation of  superficial  capillaries  with  obliteration  of  large  vessels 
and  deeper  anastomosing  capillaries,  due  to  proliferation  of  endothe- 
lium and  thickening  of  the  media  with  subsequent  thrombosis;  de- 
struction of  the  hair  follicles  and  sebaceous  glands  following  long 
or  repeated  exposure;  appearance  of  abnormal  cells.  It  is  easy  to 
see  that  such  vascular  and  lymphatic  changes  would  cause  serious 
nutritional  disturbances  and  as  a  result  there  is  hypertrophy  of  the 
epidermis  with  keratosis  in  places,  and  in  other  areas  atrophy  and 
necrosis  which  give  rise  to  dry,  superficial  and  deep,  indolent  ul- 
cers usually  having  tough  adherent  membranes  and  which  heal  im- 
perfectly, leaving  hard,  poorly  vascular  scars  which  tend  to  break 
down  readily.  In  some  cases  repair  is  never  complete.  With  such 
areas  of  necrosis  alternating  with  areas  of  active  epithelial  prolifera- 
tion it  is  not  unusual  to  find  strands  of  epithelial  cells  invading  the 
deeper  structures  and  thrombosed  capillaries,  with  formation  of  ac- 
tual skin  cancer.  Destruction  of  lymphocytes  due  to  action  of  the 
rays  of  blood-forming  organs,  particularly  of  the  lymphogenous 
type,  is  commonly  seen. 

Similar  conditions,  though  not  so  severe,  are  seen  following  exces- 
sive exposure  to  radium. 

Symptoms. — The  systemic  symptoms  which  accompany  this  lesion 
of  first  degree  are  comparatively  slight,  except  in  nervous  individuals 
who  are  markedly  influenced  by  pain. 


POSTOPERATIVE   BURNS  157 

It  is  commonly  believed  that  a  temperature  of  150°  F.,  or  higher, 
will  produce  a  burn  of  the  second  degree,  this  being  especially  true 
if  prolonged  contact  with  the  destructive  agent  be  maintained  for 
a  long  time.  The  appearance  of  such  a  burn  does  not  differ  very 
markedly,  except  in  extent,  from  that  of  the  first  degree.  The  sys- 
temic symptoms  are  decidedly  more  pronounced  than  in  burns  of  the 
first  degree,  this  being  especially  true  if  an  infection,  which  at  times 
is  avoided  with  difficulty,  takes  place.  While  the  suffering  may  at 
first  not  be  more  pronounced  than  in  burns  of  the  first  degree,  it  has 
a  tendency  on  the  other  hand,  to  be  of  much  greater  duration.  In 
fact,  with  nervous  individuals  it  may  last  almost  indefinitely. 

In  a  burn  of  the  third  degree  the  systemic  symptoms  are  in  pro- 
portion to  the  amount  of  tissue  destruction,  although  pain  is  not  so 
frequently  complained  of  as  in  the  first  two  types  described,  for  the 
simple  reason  that  nerve  filaments  and  trunks  have  gone  the  same 
way  of  other  exposed  tissues  in  the  general  destructive  process.  In 
a  few  days  the  slough  begins  to  separate,  and  if  all  goes  well,  granu- 
lation tissue  makes  its  appearance  in  the  walls  of  the  defect.  If  a 
serious  infection  has  been  prevented,  the  granulation  tissue  normally 
is  converted  into  a  scar,  which  contains  no  hair  follicles,  sebaceous 
glands,  or  chorionic  villi,  but  is  merely  covered  by  a  flat  stretch  of 
surface  epithelium,  the  results  of  ingrowths  from  the  borders  of  the 
defect,  or  else  the  product  of  skin  grafting.  Such  scars  have  two 
most  undesirable  tendencies.  In  the  first  place,  keloids  may  result 
from  them,  or  their  tendency  to  contract  may  produce  most  hideous 
and  crippling  deformities. 

If  the  burned  area  is  extensive,  the  accompanying  shock  may  be  very 
marked.  It  is  quite  commonly  thought  that  destruction  of  one-half  the 
body  surface  is  sure  to  result  in  death,  although,  of  course,  this  de- 
pends very  largely  on  individual  resistance.  One  can  quite  easily 
imagine  an  individual  in  whom  a  very  much  less  extensive  burn 
than  that  just  mentioned,  might  result  fatally. 

Of  course,  we  do  not  often  see  extensive  burns  during  postopera- 
tive treatment.  However,  the  amount  of  shock  following  such  an  ac- 
cident, occurring  in  the  course  of  a  tedious  convalescence,  might  be 
expected  to  be  disproportionately  greater. 

It  may  be  stated  in  general,  that  the  extremes  of  life  do  not  bear 
the  effects  of  burns  very  well.  This  holds  good  for  the  postoperative, 
as  well  as  for  the  ordinary  variety. 

If  the  burned  surface  has  been  extensive,  we  note  that  the  urine 
is  highly  acid,  small  in  amount,  contains  albumin,  and  frequently 
casts.     Blackfan  and  Higgins7  of  the  Johns  Hopkins  Hospital  have 


158  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

found  that  there  is  frequently  an  acidosis  in  children  suffering  from 
superficial  burns.  The  acidosis  may  develop  within  a  few  hours  after 
the  injury,  or  it  may  he  present  as  a  terminal  manifestation.  The 
earliest  clinical  sign  of  acidosis  is  hyperpnea.  The  laboratory  evi- 
dence of  the  acidosis  was  established  by  diminished  alveolar  carbon 
dioxide  tension  and  a  diminution  of  the  alkali  reserve  of  the  blood. 
The  cause  of  the  acidosis  has  not  been  determined  definitely.  It  is 
not  due  to  the  acetone  bodies,  it  may  prove  to  be  due  to  retention  of 
acid  phosphates,  dependent  upon  kidney  deficiencies.  If  so,  then  it 
is  analogous  to  that  occurring  in  nephritis  as  has  been  demonstrated 
by  Howland  and  Marriott.  The  acidosis  in  burns  is  only  one  symp- 
tom and  is  probably  not  the  cause  of  death,  but  its  presence  indi- 
cates vigorous  therapeutic  measures.  They  simjjvst  as  the  result  of 
their  observations  that  alkalies  be  given  prophylactically  after  se- 
vere burns,  and  when  an  acidosis,  as  determined  clinically  by  the 
hyperpnea,  or  by  one  of  the  laboratory  tests,  develops,  energetic 
treatment  with  alkalies  be  instituted.  It  lias  also  been  noted  by  some 
authors  that  a  transitory  glycosuria  results  in  a  few  eases  and  it  ap- 
parently is  not  necessary  that  the  burn  he  severe  to  bring  about  tins 
complication. 

Frostbite 

For  want  of  a  better  term  in  describing  the  action  of  cold,  as  we 
occasionally  see  it  in  postoperative  treatment,  we  have  adopted  the 
caption  "frostbite."  Ormsby8  in  discussing  this  subject  states  that 
•-in  the  first  degree  injury  which  usually  follows  short  exposure  to 
extreme  cold,  there  occurs  erythema  and  then  swelling  after  the  parts 
are  warmed.  During  the  freezing  process  there  occurs  slight  pain 
followed  by  loss  of  sensation,  and  the  area  presents  a  pale  appear- 
ance from  contraction  of  the  blood  vessels.  As  the  circulation  is  re- 
stored, hyperemia  and  edema  follow.  <  Occasionally  a  more  or  less  per- 
manent redness  supervenes. 

••In  the  second  degree  the  edema  and  erythema  are  increased  with 
the  production  of  vesicles  and  bullae.  These  undergo  involution  with- 
out the  formation  of  scars. 

"In  the  third  grade  gangrene  may  occur  with  and  without  the  for- 
mation of  bullae.  The  frozen  part  may  become  insensitive,  white,  and 
cold,  without  the  circulation  in  it  of  blood  and  lymph  currents.  From 
this  condition  reaction  occurs,  with  the  formation  of  an  eschar,  dif- 
fering according  to  the  severity  of  exposure  to  cold.  If.  however, 
besides  the  interference  with  the  circulation,  the  tissue  itself  has  been 
destroyed,  when  reaction  occurs  the  parts  fall  at  once  into  gangrene; 


POSTOPERATIVE    BURNS  159 

or  there  form  bulla?,  larger  than  those  described  above,  filled  with 
sanguinolent  serum;  or  the  skin  is  smooth,  marbled  with  bluish  lines, 
whitish,  cold,  and  insensitive.  Gangrene  ensues,  followed  by  the 
well-known  phenomena  of  the  'line  of  demarcation,'  and  separation 
of  the  dead  part,  granulation,  repair,  and  cicatrization." 

Prognosis. — The  prognosis  of  burns  or  frostbite  in  the  after-treat- 
ment can  hardly  be  put  upon  the  serious  plane  which  often  charac- 
terizes these  lesions  at  other  times,  since  fortunately,  such  accidents  in 
the  hospital  do  not  result  in  the  extensive  tissue  destruction  often  seen 
in  burns  of  the  customary  variety.  It  is  well  to  add  in  this  connec- 
tion, that  it  is  the  extent  rather  than  the  depth  of  a  burn  which  is 
especially  serious,  as  far  as  the  life  of  the  individual  is  concerned. 

The  most  serious  complication  likely  to  ensue  after  a  postoperative 
burn  is  an  infection.  Fortunately,  however,  for  the  individual  so 
unfortunate  as  to  be  injured  within  the  hospital  walls,  we  are  usually 
in  a  position  to  prevent  or  combat  this  secondary  complication.  Tu- 
dor9 reminds  us  of  one  matter  important  in  this  connection,  that  the 
anaphylactic  reaction  which  follows  the  absorption  of  toxins  from 
burned  tissues  is  not  to  be  overlooked  as  an  important  factor  in  these 
cases. 

About  the  worst  prognostic  features  in  postoperative  burns  are 
deformities,  sears,  prolonged  stay  in  the  hospital,  the  patient's  dam- 
aged morale  and  the  heightened  tendency  to  malpractice  suits. 

Treatment. — So  many  remedies  have  been  proposed  in  the  treat- 
ment of  burns  that  one  can  be  reasonably  sure  that  not  many  of  them 
are  highly  satisfactory.  I  no  longer  employ  any  of  the  oils,  picric 
acid,  or  one  of  the  other  thousand  and  one  agents  which  discolor  the 
individual's  skin  or  render  his  habiliments  greasy  and  unfit  for  fur- 
ther use.  We  have  not  found  a  chemical  substance  which  is  pro- 
ductive of  immediate  relief  from  pain  when  used  as  a  local  applica- 
tion. To  accomplish  this  highly  desired  result,  we  rely  upon  mor- 
phine alone,  and  know  of  no  other  drug  which  in  any  measure  will 
take  its  place.  We  think  of  nothing  more  cruel  at  this  time  than  the 
application  of  a  gauze  or  cotton  dressing,  which  must  be  changed  at 
intervals  and  thus  subject  the  damaged  and  oversensitive  tissues  to 
repeated  traumata.  So  far  as  I  can  judge  at  the  present  time,  there 
seem  to  be  just  two  reasonable  courses  open  to  us  in  treating  a  burn, 
no  matter  what  the  degree. 

Presupposing  in  both  eases  that  the  part  has  first  been  put  at  rest 
and  kept  so,  we  may  cover  the  burned  area  with  paraffin  and  com- 
pletely exclude  the  air,  and  in  this  way  may  obtain  the  maximum  of 
relief,  and  at  the  same  time  do  a  great  deal  toward  preventing  ac- 


160  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

eidental  infection.  While  this  suggestion  is  by  no  means  a  new  one, 
still.  I  think  we  may  safely  claim  for  it  that  one  of  the  many  con- 
tributions, which  the  genius  of  the  French  has  made  to  clinical  sur- 
gery during  the  great  war,  is  the  treatment  of  burns  with  a  coating 
of  paraffin.  Howarth,10  after  much  experimenting  is  convinced  that 
patients  are  made  much  more  comfortable  and  that  healing  is  has- 
tened by  daily  applications  of  paraffin,  either  in  the  form  of  a  liquid 
spray  or  if  put  on  with  a  brush,  or  even  if  applied  as  a  plaster  on 
cotton. 

The  material  must  be  made  flexible  by  a  slight  modification,  the 
following  prescription  being  suggested. 

Paraffin,  70  gm. 

Liquid   petrolatum,   3   c.c. 

"White  beeswax,  10  gm. 

This  is  to  be  melted  in  a  double  boiler,  and  applied  after  the  sur- 
face has  been  dried  by  the  electric  fan,  else  this  layer  will  not  adhere. 

The  second  choice,  to  which  I  have  referred,  in  the  treatment  of 
burns,  concerns  itself  with  the  immediate  exposure  of  the  affected  area 
to  the  air,  the  body  heat  being  kept  up  by  means  of  a  number  of  elec- 
tric light  bulbs  swung  from  the  cradle  which  holds  the  bed  covers 
off  the  exposed  part,  or  else  the  patient  is  placed  in  a  burn  bed. 
The  crusts  may  be  softened  by  applying  every  few  hours  4 
per  cent  boric  acid  ointment,  which  after  being  retained  on  the 
lesion  for  one  hour  is  again  gently  scraped  off,  the  patient  all  the 
u  hilf  being  kept  under  the  direct  rays  of  the  electric  light.  The  object 
of  the  light  is  to  act  as  a  drying  agent,  at  the  same  time 
maintaining  body  heat  so  that  a  patient,  though  partly  or  even 
completely  undressed  and  exposed,  may  lie  in  comfort.  In  order  to 
gain  sufficient  heat  it  is  sometimes  necessary  to  replace  the  tungsten 
electric  light  bulb  by  the  old-fashioned  carbon  filament  bulbs,  which 
emit  less  light  but  give  considerably  more  heat.  Light  and  heat  are 
further  regulated  by  decreasing  or  increasing  the  number  of  bulbs 
or  more  lightly  covering-  the  cradle,  depending  on  the  amount  of 
either  desired.  Ravogli11  instead  of  continuing  the  open  air  treat- 
ment, even  while  the  boric  ointment  has  been  applied,  covers  the  part 
with  "English  Lint."  I  do  not  consider  this  absolutely  necessary,  at 
least  in  many  cases,  and  it  may  dislodge  the  various  small  islands  of 
epidermis  which  have  in  the  meantime  sprung  up  here  and  there  over 
the  granulations. 

Let  us  suppose  that  in  the  course  of  time,  all  the  sloughs  have 
come  away  or  have  been  removed,  and  the  wound  has  become  clothed 
with  healthy,  velvet  like  granulation  tissue.     As  the  epithelium  from 


Fig.  23. — Skin  grafts  on  an  extensive  burn  surface. 


POSTOPERATIVE    BURNS 


161 


the  skin  edges  creeps  over  the  granulating  wound,  its  progress  is 
hastened  by  placing  each  day  new  areas  of  Reverdin  skin  grafts 
(Fig.  23),  which  will  readily  take  over  the  areas  of  healthy  granula- 
tion tissue.  If  for  any  reason  the  granulations  are  pale  and  whitish, 
as  is  seen  often  after  x-ray  burns,  balsam  of  Peru  may  be  applied 
along  with  the  treatment  discussed  above,  and  here  small  grafts  of 
the  whole  thickness  of  the  skin,  after  the  Wolfe-Krause  method,  may 
be  applied  without  awaiting  for  areas  of  healthy  tissue  to  appear. 
It  will  be  found  that  some  will  take  and  from  around  them  the  gran- 


Fig.  24. — Wire  cage  to  protect  skin  grafts   on  burn  surface. 


ulation  will  become  normal  in  appearance.  In  carrying  out  the  skin 
grafting,  the  skin  should  be  taken  from  the  patient  himself.  A  solu- 
tion of  y2  per  cent  novocaine  with  1 :1000  c.c.  adrenalin  in  salt  solu- 
tion being  used  to  anesthetize  the  skin  area.  A  sharp  pair  of  scis- 
sors and  a  pair  of  small  mouse  tooth  forceps  are  all  one  needs  in  se- 
curing the  grafts. 

I  recall  a  patient  who  was  severely  burned  while  the  results  of  a 
bismuth  meal  were  being  observed.  The  lesion,  a  third  degree  burn, 
extended  over  a  considerable  region  of  the  back.     After  months  of 


162  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

treatment  with  all  the  methods  advised  in  the  foregoing  paragraphs, 
most  of  the  defect  was  healed.  The  epidermis  regenerated,  and  fi- 
nally nicely  covered  the  whole  region  except  for  a  bat-shaped  area  four 
inches  long  and  three  inches  wide  in  the  center  of  the  small  of  the 
back.  This  was  filled  in  with  pale  granulation  tissue  and  was  ex- 
tremely painful.  This  area  was  excised  in  its  entirety  and  allowed 
to  fill  in  wdth  new  granulation  tissue  which  was  indeed  slow  to  de- 
velop. The  part  was  covered  with  an  ordinary  wire  sieve  (Fig.  24) 
and  the  patient  allowed  up  and  around  out  of  doors.  The  new  granu- 
lations were  whitish  and  certainly  not  healthy  in  appearance,  but  the 
operative  procedure  had  stopped  the  pain  which,  of  course,  is  the 
first  factor  to  consider  in  these  eases.  As  quickly  as  the  defect  filled 
with  the  new  tissue,  Wolfe-Krause  grafts  were  used,  with  the  result 
that  after  one  or  two  trials,  a  "graft  took."  Around  this  nucleus 
the  granulations  became  red  and  healthy.  This  permitted  more  suc- 
cessful  skin  grafting  and  quick  covering  of  the  denuded  area  with 
normal  skin. 

The  systemic  treatment  is  considered  very  important  in  burns  of 
any  degree.  In  those  of  second  or  third  degree,  it  is  imperative  that 
this  part  of  the  individual  case  be  not  overlooked,  while  the  local 
management  is  being  carried  out.  In  those  cases  requiring  the  open 
air  treatment  from  the  very  first,  I  do  not  hesitate  to  give  morphine, 
as  it  is  needed  for  the  first  few  days;  it  apparently  aids  materially 
in  combating  the  shock. 

We  are  not  often  confronted  by  a  serious  acidosis  or  other  form  of 
autointoxication  in  the  relatively  restricted  burns  which  occur  dur- 
ing surgical  after-treatment;  still,  it  may  not  be  amiss  to  mention  in 
this  connection  the  fact  that  the  use  of  sodium  solution,  morphine, 
carbohydrate  feeding  and  plenty  of  water  are  of  use  in  this  connec- 
tion. 

In  the  treatment  of  injuries  due  to  cold,  the  same  local  and  general 
measures  may  be  employed  as  discussed  for  like  injuries  due  to  heat. 
At  first,  cold  applications  may  be  applied  to  the  injured  surface,  as 
the  pain  in  most  cases  will  be  too  severe  to  suddenly  cause  marked 
reaction  by  the  application  of  heat. 

Full  credit  is  due  ( ).  F.  McKittrick  for  having  abstracted  all  the 
literature  to  which  reference  is  made   in  this  chapter. 

Bibliography 

iSajous:     Analytic  Cyclopedia  of  Practical  Medicine,  1917,  viii,  171. 
zBardeen:     Jour.  Exper.  Med.,  Is:i7,  ii,  501.     Also  Johns  Hopkins  Hosp.  Eepts., 

1898    (7),  p.   137. 
sWeiskotten :     .lorn.  Am.   Med.  Assn..  Sept.  8,   1P1 7  :   ibid.,  Jan.  25,   1919. 
iVogt:     Ztsdir.  exper.  Path.  u.  Pharm.,   L912,  ii,  L91. 


POSTOPERATIVE   BURNS  163 

sLocke:     Boston  Med.  and  Surg.  Jour.,  1902,  cxlvii,  480. 

GWolbach:     Jour.  Med.  Eesearch,  October,  1909,  xxi,  415. 
Porter:  Ibid.,  p.  357. 

^Blachfan  and  Higgins:     Personal  communication. 

sOrmsby:     Diseases  of  the  Skin,  Philadelphia,  1915,  Lea  &  Febiger,  p.  266. 

sTudor:     Internat.  Jour.  Surg.,  1915,  xxviii,  286. 
loHowarth:      Surg.,   Gynec.  and  Obst.,  November,   1917. 
nBavogli:     Jour.  Am.  Med.  Assn.,  1915,  lxv,  293. 
The  following  references  were  also  consulted: 
Abbe:     Jour.  Am.  Med.  Assn.,  July  17,  1915,  p.  220. 
Bernard:     Munchen.  med.  Wchnschr.,  Jan.  5,  1904. 
Boland:     New  York  Med.  Jour.,  August,   1913. 
Brazer:     New  York  Med.  Jour.,  1913,  p.  236. 

Brooks :     General  and  Special  Pathology,  Philadelphia,  1916,  P.  A.  Davis  Co. 
Chipman:     Jour.  Am.  Med.   Assn.,  1915,  lxv,  295. 
Copeland:     Med.  Bee,  New  York,  May,  1887. 

Da  Costa:     Modern  Surgery,  Philadelphia,  1918,  W.  B.  Saunders  Co.,  ed.  7. 
Delafield    and    Prudden:     Textbook    of    Pathology,    Philadelphia,    1914,    W.    B. 

Saunders  Co.,  ed.  9. 
Freeman:     Analytic    Cyclopedia    of    Practical    Medicine,    Philadelphia,    1917,    F. 

A.  Davis  Co.,  viii,  163. 
Heithaus :     Personal  communication. 
Heyde:     Med.  Klin.,  1912,  viii,  263. 
Jack:     Washington  Med.  Ann.,  1911-13,  x-xi,  106. 
Kaposi:     Pathologie  et   traitement   des  Maladies   de  la  peau,   trans,   by  Besnier 

and  Dayon,  Paris,  1896. 
Keen:     Surgery,  Philadelphia,  W.  B.  Saunders  Co. 
Kuss:     Paris  Medical,  Feb.  21,  1914. 
Lieber:      Beitr.   z.  klin.   Chir.,   1912,   lxxxi. 
Lutz:     Bailway  Surgeon,  July  25,  1899. 

MacCallum:     A  Text  Book  of  Pathology,  Philadelphia,  1917,  W.  B.  Saunders  Co. 
McArthur:     Am.  Jour.  Boentgenol.,  1917,  iv,  521. 
McDonnell:  Jour.  Cutan.  Dis.,  1915,  p.  312. 
Parker:      Surg.  Clin.,  Chicago,  1917,  i,  635.     Also  Jour.  Am.   Med.  Assn.,   Aug. 

19,  1916. 
Pfeift'er:      Ztschr.   Immunitat.,  1913,  xviii,   75. 
Pusey:     Jour.  Am.  Med.  Assn.,  1915,  lxv,  295. 
Beid:     Lancet,  London,  March,  1898. 

Bosslenger:     Internat.  med.  Kong.,  Wien,  September,  1892. 
Sequeira:     Brit.  Jour.  Dermat.,  1908,  p.  140. 
Sherman:     Surg.,  Gynec.  and  Obst.,  1918,  xxvi,  450. 

Shoemaker:     Diseases  of  the  Skin,  Philadelphia,  1909,  F.  A.  Davis  Co.,  p.  344. 
Stelwagon:     Diseases  of  the  Skin,  Philadelphia,  1916,  W.  B.  Saunders  Co. 
Sneve:     Jour.     Am.  Med.  Assn.,  1905,  xlv,  1. 
Talmey:     The  Open  Air  Treatment  of  Burns,  New  York  Med.  Jour     1914    xcix 

p.  549.  '  ' 

Tudor:     New  York  Med.  Jour.,  1918,  cvii,  404,  453. 
Wagner:     Zentralbl.  f.  Chir.,  Dec.  12,  1903. 

Wells:     Chemical  Pathology,  Philadelphia,  W.  B.  Saunders  Co.,  ed.   3. 
Wertheimer:     Munchen.  med.  Wchnschr.,  1892,  No.  21. 
Zeisler:     Jour.  Am.  Med.  Assn.,  1915,  lxv,  295. 


CHAPTER  XX 

BEDSORES 

By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Bedsores  have  been  the  subject  of  considerable  discussion  and 
writing  throughout  the  years  of  medical  and  surgical  advance.  It  is 
one  ever  requiring  the  most  minute  attention  of  those  in  charge  of 
the  unhappy  victim  and  even  then,  the  ultimate  outcome  may  be  such 
as  to  seriously  impede  the  recovery  of  infirm  patients,  particularly 
after  a  major  operation. 

The  lesion  is  a  local  anemia  which  finally  results  in  moist  gangrene 
due  to  continued  pressure  on  some  particular  area.  Zipperling,1  who 
has  recently  considered  this  complication,  states  that  Samuel,-  in  his 
study  of  the  effects  upon  the  skin  and  underlying  tissues,  was  the 
first  to  give  the  name  "decubitus"  to  these  lesions. 

Zipperling  in  discussing  lesions  of  the  spinal  cord  and  brain  has 
observed  decubitus  develop  apparently  from  tins  source  alone  and 
refers  to  Leyden,  who,  lie  says,  first  made  a  short  mention  of  "Acute 
Decubitus"  in  his  text  book.  Later  on  Erlr  fully  described  the 
malady.  His  writings  were  soon  followed  by  those  of  Eulenburg.1 
That  injuries  and  lesions  of  the  cord  or  brain  may  cause  decubitus 
has  been  held  true  by  others  although  the  general  opinion  that  lesions 
here  are  more  commonly  predisposing  rather  than  causative  factors 
has  recently  been  supported  by  Marie  and  Roussy.s  These  men 
working  among  the  wounded  during  the  last  war  state  that  the 
various  paralyses  resulting  from  injuries  or  lesions  of  the  cord  or 
brain  prevent  the  patient  from  changing  his  position  as  he  would 
otherwise  do  and  that  the  associated  loss  of  sensation  disparages  any 
inclination  to  move.  As  a  result  of  this  certain  parts  of  his  body 
constantly  support  his  weight  and  bedsores  appear  <  Figs.  25  and  26). 
Especially  is  this  true  if  there  is  an  incontinence  of  feces  or  urine. 
In  such  patients  it  is  not  imperative  that  the  pressure  be  necessarily 
very  severe  or  prolonged  to  cause  marked  local  anemia  and  final 
gangrene.  Bedsores,  therefore,  in  these  patients  are  indeed  very  ser- 
ious since  the  destruction  of  the  tissues  is  so  rapid  and  the  healing 
power  so  limited. 

164 


BEDSORES 


165 


Fig.  25. — Bedsores   following  myelitis.      (After   Keen.) 


Fig.  26. — Healed  bedsores.      (After  Keen.) 


166  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

Decubitus  also,  is  seen  in  patients  with  no  cerebral  or  spinal  affec- 
tions, but  in  those  who  because  of  their  condition  are  obliged  to  re- 
main in  bed  for  any  length  of  time.  The  emaciated  and  otherwise 
weakened  patients  are  more  liable  to  this  affection  than  those  of 
stouter  builds,  although  this  malady  may  affect  any  patient  who  is 
in  bed  even  for  a  limited  time  if  there  is  too  prolonged  local  pressure 
on  the  tissues.  Thus  pressure  from  an  improperly  applied  bandage, 
splint,  or  plaster  of  Paris  dressing  may  do  untold  damage  within  a 
short  time  if  the  accompanying  pain  complained  of  by  the  patient  is 
not  heeded. 

Pressure  from  bed  clothes,  particularly  over  the  toes,  wrinkles  in 
the  sheet  or  patient's  gown,  bread  crumbs,  pins,  strings  in  the  bed 
will  cause  this  complication. 

Inactivity  of  the  patient,  excessive  secretions,  regardless  of  the  na- 
ture, predispose  to  bedsores,  especially  if  the  skin  is  not  kept  scrupu- 
lously clean,  and  even  then,  the  lesion  will  sometimes  occur  despite 
the  best  nursing. 

The  lesion  most  usually  occurs  over  the  bony  prominences  corre- 
sponding to  the  sacrum,  coccyx,  or  tuber  ischii.  They  occur  also  over 
the  back,  along  the  spine,  on  the  heel,  over  the  malleoli  or  point  of 
the  elbow.  In  fact  pressure  on  a  part  of  the  body  may  produce  a  le- 
sion in  a  most  unexpected  place,  depending  on  the  position  of  the  pa- 
tient. There  is  first  a  reddening  of  the  skin  which  is  usually  accom- 
panied by  a  burning  pain  more  or  less  severe.  Unfortunately  at  times, 
very  little  or  no  pain  is  complained  of  and  the  sore  is  found  quite  by 
accident,  Following  the  redness  of  the  skin  at  the  point  of  pressure 
there  oecurs  a  bluish  discoloration,  probably  spotted  at  first,  which 
soon  changes  to  a  solid  brownish  or  black  color.  Vesicles  or  bullae 
may  form  here  and  there  over  the  area,  and  these  finally  rupture. 
Leaving  an  ulcerating  surface  which  soon  becomes  necrotic.  This 
necrosis  may  involve  muscles,  tendons,  and  occasionally  even  bones. 
A  line  of  demarcation  forms  sooner  or  later,  and  under  proper  care 
the  tissue  sloughs  out,  the  defect  healing  by  granulation. 

As  a  rule  the  bedsore  does  not  become  so  extensive ;  an  ulceration 
of  the  skin  and  possibly  subcutaneous  tissues  being  its  extent,  al- 
though in  some  cases  destruction  does  not  stop  even  at  the  bone  but 
passes  on  into  the  spinal  canal,  causing  meningitis  and  death."  That 
dire  consequences  can  occur  from  these  lesions,  due  to  infection  or 
extension  of  the  process  must  always  be  borne  in  mind  and  measures 
instituted  to  combat  both  these  possibilities  as  soon  as  the  trouble  is 
discovered. 


BEDSORES  167 

Much  has  been  written  on  the  treatment  of  bedsores.     The  most 
important  result  one  can  hope  to  attain  is  to  prevent  them.    Patients 
on  admittance  to  the  hospital  are  given  thorough  cleansing  baths 
with  soap  and  water  followed  by  an  alcohol  rub  (50  per  cent)  twice 
each  day  until  the  operation.     This  not  only  keeps  the  skin  clean, 
but  tends  to  harden  it.     They  are  placed  in  comfortable  beds  with 
smooth  uniform  mattresses,  over  which  the  sheets  are  kept  stretched, 
and  if  necessary,  pinned  to  the  mattresses  to  prevent  possible  creases 
or  folds  occurring.     The  importance  of  keeping  bread  crumbs  and 
other  foreign  particles  out  of  the  bed  is  self  evident.    The  skin  must 
be  kept  dry,  a  task  not  always  easy  of  accomplishment.     The  pro- 
verbial rubber  sheet  on  every  hospital  bed  is  sufficient  in  itself  to 
cause  some  patients  to  perspire  freely,  particularly  in  hot  weather. 
This  should  be  removed  in  such  instances  and  the  clanger  to  the  mat- 
tress met  by  using  strips  of  rubber  as  the  occasion  demands.     Occa- 
sionally it  becomes  necessary  to  replace  the  rubber  sheet  with  some 
absorbent  material  which  will  dispose  of  the  perspiration  as  cpiickly 
as  it  forms.     The  value  of  this  procedure  was  recently  extolled:  by 
Smith6  who  though  a  helpless  invalid  was  bedridden  over  five  years 
without  a  lesion  developing.     In  this  connection  we  also  freely  use 
boric  acid  powder,  equal  parts  of  boric  acid  with  bismuth  subnitrate, 
or  even  talcum  powder  to  dust  over  the  body  as  often  as  necessary  to 
keep  the  skin  dry.    This  procedure  is  also  particularly  useful  follow- 
ing the  sponge  bath  and  alcohol  rub.     Where  there  is  an  inconti- 
nence of  urine  a  rubber  urinal  is  constantly  worn.    When  the  patient 
is  incontinent  both  as  to  the  feces  and  urine  he  is  washed,  as  soon  as 
soiled,  with  warm  water  and  castile  soap,  given  an  alcohol   (50  per 
cent)  rub  to  which  alum,  10  grains  to  the  pint,  has  been  added.    Ac- 
cording to  Lind7  this  is  repeated  after  every  soiling,  and  if  there  is 
any  redness  of  the  skin  in  the  regions  repeatedly  soiled  he  would 
apply  zinc  oxide  ointment  (U.  S.  P.)   I  have  found  that  a  mixture 
of  the  above  zinc  oxide,  one  ounce,  cotton  seed  oil,  two  ounces,  and 
alcohol,  two  ounces,  is  an  exceedingly  good  application  for  these 
cases.    In  fact  this  mixture  may  be  used  twice  daily  over  the  wdiole 
body  in  patients  not  so  affected  and  in  every  instance  with  the  most 
satisfactory  results.    It  is  usually  rubbed  into  the  skin  morning  and 
night  immediately  following  the  bath. 

The  Bradford  frame  is  very  valuable  in  paralyzed  patients  or  those 
suffering  from  fracture  of  the  hip.  Sucb  patients  placed  on  this  or 
some  similar  device  can  be  turned  at  will  and  any  pressure  points 
relieved  by  treatment. 

In  studying  the  various  methods  to  keep  the  skin  in  a  healthy  con- 


168  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

dition  locally,  one  must  not  forget  that  looking  after  the  general  con- 
dition of  the  patient  is  equally  important.  His  general  health  is 
carefully  watched  over  and  an  abundance  of  food  supplied. 

If  this  complication  arises  in  spite  of  every  measure  skill  and  com- 
mon sense  can  devise  to  prevent  it,  one  must  first  invent  some  means 
to  relieve  all  pressure  and  tension  from  the  affected  part.  Air  cush- 
ions, rubber  rings  or  even  a  pneumatic  or  water  bed  have  been  em- 
ployed for  this  purpose.  For  those  patients  greatly  emaciated  or 
paralyzed,  such  beds  are  indeed  valuable  in  bringing  about  an  equal 
distribution  of  the  weight.  However,  these  are  not  always  to  be  had 
and  under  such  circumstances  the  mattress  may  be  replaced  by  a  bed 
of  some  airy  soft  material  such  as  cotton,  wool  or  hair,  which  is 
thrown  loosely  into  an  improvised  bedstead.  Zweig9  employs  wood 
wool,  the  patient  being  allowed  to  lie  on  the  loose  material  which  has 
no  covering  at  all  and  is  confined  by  the  limits  only  of  an  old-fash- 
ioned wooden  bedstead.  This  maneuver,  to  be  sure,  is  not  always 
agreeable,  but  may  be  employed  in  extreme  cases.  Pressure  from  bed- 
clothes or  irritation  from  the  night  gown  is  overcome  by  the  use  of 
cradles,  wire  cages,  and  even  the  application  of  absorbent  cotton8 
placed  over  the  lesion  and  held  in  position  with  collodion  is  very  ad- 
visable in  some  instances. 

Very  small  breaks  in  the  skin  are  often  protected  by  simply  apply- 
ing an  ordinary  zinc  oxide  adhesive  strip  directly  over  the  exposed 
surface.  Where  the  lesion  is  so  large  that  neither  of  these  remedies 
is  advisable,  the  pari  is  kept  clean  with  a  saturated  boric  acid  solu- 
tion or  sterile  water,  and  then  dusted  with  boric  acid  powder.  Lind 
recommends  for  this  purpose  aristol  one  part,  boric  acid  one  part,  and 
lycopodium  eight  parts.  The  wound  is  left  open  and  exposed  to  the 
air,  this  portion  of  the  body  absolutely  relieved  of  pressure.10 

Bedsores  which  involve  the  deeper  tissues  require  more  extensive 
treatment.  In  such  instances  the  electric  Ligb.1  treatment  is  instituted. 
The  lesion  is  kept  free  of  crusts,  sloughs  are  pulled  off  whenever 
it  can  be  done  without  bleeding,  and  the  tissue  irrigated  frequently 
with  Dakin's  fluid,  boric  acid  or  hypertonic  sodium  chloride  solution. 
At  night  a  4  per  cent  boric  acid  ointment  is  placed  in  the  defect  and 
the  whole  covered  Lightly  with  gauze  or  else  a  small  wire  sieve  fas- 
tened over  the  part  by  means  of  adhesive.  The  use  of  adhesive  is  not 
desirable11  in  every  case  as  it  is  very  irritating  to  the  skin  of  some  of 
these  patients  and  in  selected  cases  only  is  it  to  be  desired  even  for 
this  simple  means.  The  next  morning  the  ointment  is  removed  lightly 
with  gauze  and  the  electric  light  treatment  resumed. 


BEDSORES  169 

In  cases  where  this  treatment  is  not  practical  in  the  usual  way  the 
rays  of  light  may  be  directed  into  the  lesion  by  means  of  a  concave 
head  mirror.  Whenever  it  is  possible  to  substitute  sunlight  for  the 
electric  light  these  rays  are  directed  into  the  wound  in  this  same 
manner.  This  was  first  suggested  by  Ring.12  It  is  remarkable  how 
quickly  such  lesions  heal  when  all  the  details  of  this  treatment  are 
persistently  carried  out. 

Decubitus  of  long  standing  and  which  show  little  or  no  tendency  to 
heal  may  be  stimulated  with  alternate  hot  and  cold  compresses.  The 
granulations  be  stimulated  by  rubbing  a  silver  nitrate  stick  over  the 
surface  occasionally.  Massage  of  the  adjacent  skin  is  also  a  valuable 
procedure.  At  night  the  boric  ointment  is  replaced.  A  mixture  ad- 
vised by  Lind  follows:  silver  nitrate  one  part,  balsam  of  Peru  ten 
parts,  zinc  oxide  ointment  one  hundred  parts,  or  the  balsam  of  Peru 
may  be  used  alone.  When  the  granulations  have  become  even  with  the 
skin  surface,  4  per  cent  scarlet  red  ointment  replaces  all  other  oint- 
ments and  the  light  treatment  is  continued. 

Multiple  bedsores  particularly  in  emaciated  or  paralyzed  patients 
may  require  a  continuous  full  warm  bath  at  a  temperature  of  95°  to 
1000.13  The  treatment  may  be  kept  up  as  long  as  desired  without 
appreciable  weakening  or  injury  to  the  general  health  and  when  there 
is  marked  improvement  in  the  lesions,  they  are  then  cared  for  as  sug- 
gested above. 

Bibliography 

iZipperling:     Centralbl.  f.  d.  Grenzgeb.,  d.  Med.  u.  Chir.,  1913,  p.  187. 

2Samuel:     Die  tropliischen  Nerven,  Leipzig,  1860. 

sErb :     Handb.  von  Ziemssen  u.  Spez.  Path.  u.  Ther.  1876,  xi,  p.  120. 

4Eulenburg:     Lehrbuch  der  Nervenkrankheiten,  Berlin,  1878,  1.  Theil  p.  343-347. 

s  Marie  and  Boussy:     Bull,  de  l'Acad.   de  Med.,   Paris,   1915,  lxxiii,   609.     Also 
abstr.  in  Internat.  Abstr.  Surg.,  1915,  xxi,  29-4. 

eSmith:     Modern  Hospital,  1916,  vii,  518. 

7Lind:     New  York  Med.  Jour.,  1915,  ci,  26. 

sCrandon :      Surgical  After-treatment,   1909,  p.  284. 

sZweig:     Deutsch.  Med.  Wchnsehr.,  1911,  xxxxii. 
loHigbee:     Bef.  Handbook  for  Nurses   (Beck),  1913,  p.  84. 
-lEhrenreich:      New  York  Med.  Jour.,  1915,  ci,  27. 
isBing:     Boston  Med.  and  Surg.  Jour..  1906,  civ.  629. 
isNeuwelt:     New  York  Med.  Jour.,  1915,  ci,  75. 


CHAPTER  XXI 

POSTOPERATIVE    PROLAPSE    OF    ABDOMINAL    VISCERA 
By  Willard  Bartlett,  St.  Louis,  Mo. 

Professor  Madelung's  exhaustive  article  with  its  105  literature  ref- 
erences which  appeared  in  1905,  leaves  absolutely  nothing  to  be  de- 
sired so  far  as  this  subject  is  concerned,  hence  I  feel  that  I  can  do 
my  readers  no  greater  service  than  to  present  a  painstaking  abstract 
of  it  as  a  chapter  on  this  subject.  Madelung1  up  to  1905,  was  able 
to  find  144  cases  in  the  literature,  had  7  in  his  own  practice,  and  6 
in  the  practice  of  several  of  his  colleagues,  thus  making  157  cases 
for  purposes  of  study.  The  accident  has  occurred  after  exploratory 
laparotomies  where  no  decrease  in  the  abdominal  contents  was  made, 
but  what  is  much  more  surprising,  it  lias  also  been  noted  after  re- 
moval of  the  largest  tumors.  It  occurred  in  the  earliest  days  of  ab- 
dominal surgery,  in  1844  for  instance,  as  well  as  in  most  recent  years 
with  all  the  modern  improvements.  It  lias  occurred  in  a  child  two 
days  old  and  in  a  woman  seventy-one  years  old.  In  women  it  oc- 
curred 118  times  and  in  men  25  times,  while  the  sex  is  not  given  in 
14  instances.  Practically  every  form  of  abdominal  and  pelvic  oper- 
ation has  been  complicated  in  this  way.  One  hundred  twenty-four 
times  the  incision  was  in  the  lower  half  of  the  abdominal  wall,  while 
in  16  instances  it  vvas  in  the  upper  half,  and  it  has  been  much  more 
common  where  the  incision  has  gone  directly  through  the  midline 
rather  than  through  one  of  the  rectus  muscles.  The  danger  of  this 
accident  seems  to  lie  especially  great  when  the  incision  goes  through 
.in  old  scar  as  noted  by  Spencer  Wells  in  1863. 

As  to  the  time  when  the  wound  is  most  likely  to  burst  open.  Made- 
lung  concludes  that  this  is  somewhere  between  the  eighth  and  ninth 
day.  (It  should  bo  noted  that  the  date  of  occurrence  can  not  always 
be  given  since  in  many  instances  it  was  discovered  by  accident. ) 

In  most  instances  the  entire  Length  of  the  wound  was  found  open. 
In  a  very  few  interesting  cases  the  viscera  did  not  come  out  through 
the  original  incision  in  the  muscle  but  through  a  fresh  tear  in  this 
tissue.  With  the  exception  of  the  spleen  and  pancreas,  every  ab- 
dominal viseiis  has  been  prolapsed  in  such  cases.  The  most  frequent 
of  them  is  the  small  intestine,  with  the  omentum  in  second  place.  In 
many  cases  the  viscera  simply  lie  between  the  wound  edges  without 

170 


POSTOPERATIVE   PROLAPSE    OF    ABDOMINAL    VISCERA  171 

being  pushed  outside  the  skin  level.  This  was  accounted  for,  no 
doubt,  by  fibrinous  peritoneal  adhesions;  often,  however,  the  pro- 
lapse was  of  tremendous  size.  The  condition  of  the  mass  has  varied 
with  circumstances ;  incarceration  of  the  intestine  being  reported  only 
once.  It  is  interesting  to  relate  in  studying  the  etiology  that  this 
unfortunate  accident  occurred  most  frequently  where  silk-worm  gut 
alone,  silk  alone,  wire  alone,  or  all  of  these  suture  materials  combined, 
have  been  used.  It  occurred  where  layer  closure,  as  well  as  "through- 
and-through"  sutures  were  used.  In  one  instance,  the  intestine  slipped 
out  between  two  through-and-through  sutures  which  had  been  placed 
rather  far  apart.  Of  course  it  has  occurred  where  catgut  alone  has 
been  employed,  but  Madelung  after  his  extensive  study  of  the  subject 
considers  it  wrong  to  conclude  that  any  special  suture  material  or 
any  one  suture  method  protects  against  bursting  of  the  wound.  It 
was  once  thought  that  the  too  early  removal  of  sutures  accounted  for 
it,  but  the  statistics  do  not  bear  out  this  conclusion,  since  it  has  often 
occurred  before  the  stitches  were  removed.  On  the  other  hand,  it 
must  be  admitted  that  the  wound  burst  thirty-nine  times  within 
twenty-four  hours  after  the  stitches  were  taken  out.  It  has  occurred, 
however,  as  late  as  the  seventeenth  day  in  a  patient  whose  stitches 
had  been  removed  nine  days  earlier.  It  does  not  seem  to  have  been 
caused  by  leaving  a  small  portion  of  a  wound  open  for  drainage,  nor 
does  tamponade  seem  to  have  had  this  effect.  (It  would  seem,  then, 
that  the  cause  of  this  distressing  accident  must  be  sought  elsewhere 
than  in  the  original  treatment  of  the  laparotomy  wound.) 

An  important  causal  factor  is  to  be  sought  in  the  condition  of  the 
abdominal  wall.  There  is  danger  where  it  is  very  thin,  especially 
in  a  greatly  weakened  individual  or  in  one  who  has  been  starved. 
Bleeding  between  the  layers  may  be  a  causal  factor,  as  may  be  local- 
ized infection.  In  most  instances,  however,  wound  healing  would 
appear  to  have  progressed  perfectly  up  to  the  moment  bursting  oc- 
curred. 

Coughing  is  surely  one  of  the  chief  causes  of  this  condition.  In  51 
out  of  these  157  cases,  it  seems  to  have  been  chiefly  to  blame,  while 
in  the  second  place,  must  be  mentioned  vomiting,  which  was  the  direct 
cause  of  the  accident  26  times.  In  some  instances  the  two  last-men- 
tioned factors  worked  together.  Straining  at  stool  is  mentioned  five 
times  in  this  connection  and  tympanites  seem  to  have  played  a  minor 
role,  surprising  as  it  seems.  Kapid  increase  of  intraabdominal  ten- 
sion in  pregnancy,  ascites,  and  the  growth  of  abdominal  tumors  has, 
in  a  few  instances,  been  responsible. 


172  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

It  is  curious  to  study  the  patient's  sensations  at  the  moment  the 
abdomen  bursts  open  and  to  note  that  they  are  frequently  far  from 
what  one  would  expect.  Very  few  have  expresse  1  severe  pain  or  a 
characteristic  feeling  of  bursting.  They  have  complained  rather  of 
general  abdominal  discomfort  and  frequently  has  this  been  so  light 
or  disappeared  so  quickly  that  the  patient  has  forgotten  to  mention 
it  at  the  time  to  a  nurse  or  doctor,  but  has  recalled  it  hours  or  days 
later  when  the  prolapse  is  discovered.  Frequently,  the  first  sensation 
has  been  that  of  something  warm  and  moist  on  the  abdomen  and 
thighs.  In  many  instances  the  most  acute  questioning  has  failed  to 
bring  out  the  fact  that  the  patient's  attention  was  ever  attracted  by 
any  unusual  sensation  at  all.  In  rare  instances,  the  patient  has  com- 
plained of  "feeling  badly"  or  shown  general  disturbances  with  col- 
lapse symptoms,  etc.  As  a  rule,  the  general  symptoms  have  remained 
good  throughout,  while  the  occasional  patient  has  expressed  the  feel- 
ing of  great  relief  when  the  stitches  gave  way.  In  most  cases  the  ac- 
cident has  been  discovered  by  observing  the  changed  appearance  of 
the  dressings.  They  have  been  soaked  with  fluid  or  bulged  to  the  ex- 
tent that  an  examination  has  been  made  and  the  viscera  discovered 
outside  the  abdominal  wall.  There  can  be  no  doubt  that  hours  and 
even  days  have  elapsed  before  many  of  these  patients  have  come  into 
the  surgeon's  hands.  This  is  especially  true  where  old  thin  scars 
have  ruptured.  How  ridiculous  it  seems,  then,  to  operate  on  the  pa- 
tient in  his  own  bed  with  a  show  of  haste,  instead  of  getting  him  into 
proper  surroundings.  A  general  anesthetic  has  been  used  many 
times,  though  it  is  not  at  all  necessary.  When  there  has  been  a  fecal 
fistula  oi'  suppuration  in  the  wall.  etc..  careful  cleansing  of  the  bowel 
is  necessary.  Where  an  aseptic  dressing  has  covered  unsoiled  viscera, 
cleansing  is  unnecessary  and  may  do  harm.  Shall  we  then  replace  the 
viscera  at  all  or  shall  we  do  it  at  once?  Of  course  the  ideal  treatment 
is  replacement  with  immediate  suture.  In  some  instances,  however, 
it  is  not  possible  to  get  the  prolapsed  contents  back  into  the  cavity. 
and  in  seven  of  the  cases  reported,  no  attempt  at  reposition  was  made. 
In  quite  a  number  of  instances  this  was  accomplished,  but  sutures 
were  not  inserted,  at  least  not  early  in  the  treatment.  Both  of  these 
acts  were  frequently  prevented  by  coughing,  meteorism.  adhesions, 
etc.  It  is  worthy  of  mention  that  spontaneous  reposition  took  place 
in  the  course  of  weeks  or  months  in  those  patients  who  could  not  or  at 
least  who  did  not  have  the  benefit  of  this  maneuver.  In  no  single 
instance  did  the  prolapse  persist,  whence  conclusion  should  be  drawn 
that  we  must  not  too  hurriedly  puncture  or  resect  intestines  which 
we  can  not  replace. 


POSTOPERATIVE    PROLAPSE    OF    ABDOMINAL   VISCERA  173 

Prolapsed  omentum  can  be  amputated  without  any  further  con- 
sideration. It  is  of  great  help  frequently  to  place  the  patient  in  the 
exaggerated  Trendelenburg  position,  while  at  the  same  time  the  edges 
of  the  wound  are  held  up  and  slight  pressure  exerted  on  the  viscera. 
It  is  often  necessary,  in  addition,  to  extend  the  original  incision  as 
well  as  to  separate  adhesions  between  intestinal  coils  or  between  them 
and  the  abdominal  wall.  This  produces  little  or  no  pain,  hence  it  is 
necessary  to  use  an  anesthetic  in  especially  difficult  cases  only.  In 
fact,  a  really  sensible  patient  can  aid  the  procedure  greatly  by  his 
voluntary  efforts.  Sometimes  a  second  attempt  succeeds  after  the 
first  has  failed,  hence  the  operator  is  not  to  give  up  after  a  single 
trial.  Some  are  in  favor  of  freshing  the  wound  edges  in  the  customary 
manner  before  suturing  is  attempted.  This  latter  procedure  is  some- 
times exceedingly  difficult ;  the  tissues  may  be  friable  and  the  sutures 
may  cut  through  or  it  may  be  impossible  to  approximate  the  edges 
so  that  gauze  must  fill  out  the  defect.  Of  course  every  form  of  second- 
ary suture  has  been  used  in  these  cases  but  apparently  one  method 
is  about  as  good  as  another.  In  many  of  the  cases  where  reposition 
has  been  made  without    suture,  tamponade  has  been  resorted  to. 

The  direct  consequences  of  treating  this  condition  as  outlined  above 
have  been  astonishingly  slight  and  the  bowels  have  moved  as  though 
nothing  had  happened.  In  a  few  instances,  however,  hasty  attempts 
at  reposition  have  been  attended  with  serious  consequences.  Intestine 
and  bladder  have  both  been  injured  by  a  rough  attempt  at  treatment. 
In  quite  a  number  of  cases,  secondary  prolapse  has  taken  place  though 
not  so  often  as  one  would  expect,  when  the  original  method  of  treat- 
ment is  considered.  Peritonitis  has  developed  in  astonishingly  few 
of  these  cases.  The  most  frequent  complications  to  arise  have  been 
those  affecting  the  respiratory  system.  (No  doubt  this  is  in  some 
measure  accounted  for  by  the  fact  that  secondary  sutures  have  been 
supported  for  a  long  time  by  adhesive  straps,  binders,  etc.,  which 
have  interfered  with  free  movements  of  the  lower  ribs  and  dia- 
phragm.— Author's  note.) 

The  prognosis  in  such  cases  does  not  depend  upon  the  kind  of  vis- 
cera prolapsed,  or  upon  the  size  of  the  mass,  or  upon  the  time  which 
has  elapsed  before  treatment  is  instituted.  One  hundred  five  of  the 
148  patients  whose  result  is  known  were  reported  as  completely  cured. 
The  scar  deserves  special  mention.  It  must  have  been  a  satisfactory 
one,  since  no  mention  was  made  at  all  in  most  of  the  histories.  It  is 
reported  18  times  as  having  been  a  perfect  one  after  many  years, 
while  it  is  definitely  stated  11  times  that  no  hernia  occurred.     This 


174  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

is  even  true  in  cases  of  multiple  ruptures  even  though  no  suture  was 
employed. 

In  one  case  the  same  wound  hurst  twice,  the  first  time  in  conse- 
quence of  heavy  lifting  and  the  second  time  two  years  later  (Synak). 
The  bursting  of  healed  laparotomy  scars  is  reported  in  16  women  and 
2  men.  In  all  of  these,  a  most  unusual  thinning  out  of  the  scar  had 
taken  place.  There  seemed  to  have  been  very  little  cause  known  for 
this  bursting,  the  patients  were  surprised  and  in  fact,  it  occurred 
twice  during  sleep.  In  a  few  cases,  however,  there  was  a  slight 
strain,  such  as  sneezing,  coughing,  bowel  movement,  lifting  of  a 
weight  or  jumping  from  a  height.  The  patient  had  become  aware 
of  his  condition,  only  upon  feeling  something  soft,  warm,  and  moist 
on  the  abdomen  and  thighs.  Usually,  the  tear  was  of  short  length, 
but  at  times,  the  amount  of  prolapsed  viscera  has  been  enormous. 
The  prognosis  in  these  instances  of  remote  prolapse  must  be  surpris- 
ingly good,  since  not  one  of  the  18  patients  died.  All  of  these  pa- 
tients were  sewed  up,  but  two,  in  whom  tampon  was  resorted  to.  No 
recurrence  took  place,  and  in  only  one  did  hernia  appear. 

In  only  one  of  the  157  cases  is  a  hernia  of  such  size  as  to  require 
operation,  reported.  Impairment  of  intestinal  function  was  reported 
only  once.  It  must  then  be  concluded  that  very  little  remote  trouble 
is  to  be  expected  by  the  individual  who  has  sustained  this  accident, 
as  a  consequence  of  his  rather  horrifying  experience.  A  critical  sur- 
vey of  these  157  cases  would  indicate  that  immediate  death  was 
caused  by  the  accident  only  29  times. 

(The  author  of  this  chapter  lias  been  so  unfortunate  as  to  have  ex- 
perienced this  embarrassing  complication  seven  times.  All  were  clean 
eases  in  which  reposition  and  secondary  suture  within  a  few  hours 
were  carried  out  without  great  difficulty.  All  the  patients,  with  but 
one  exception,  were  taken  to  the  operating  room  and  completely  closed 
up  with  through-and-through  sutures,  ether  being  used  only  once. 
The  other  six  closures  were  accomplished  with  seemingly  very  little 
pain  in  the  absence  of  even  a  local  anesthesia.  This  we  credit  to  very 
gentle  manipulation  and  the  use  of  exceedingly  sharp  cutting  needles, 
of  the  Reverdin  type.) 

BibliogTaphy 

iMadelung:     Ueber  den  Post-operativen  Vorfall  van  Baucheingaweiden,  Arch.  f. 
Klin.  Chir.,  L905,  Ixxvii,  347. 


CHAPTER  XXII 

FOREIGN  BODIES  LOST  IN  THE  PERITONEAL  CAVITY 
By  Willard  Bartlett,  St.  Louis,  Mo. 

Sir  John  Bland-Sutton  once  said,  in  his  inimitable  way,  ''before 
closing  the  abdomen  count  your  sponges,  instruments,  and  assist- 
ants. ' ' 

It  is  really  surprising  that  our  horror  at  accidentally  leaving  foreign 
substances  in  the  peritoneal  cavity  or  other  tissue  spaces  did  not 
long  ago  influence  us  strongly  against  permanently  embedding  them 
as  supports,  splints,  etc.  It  is  only  within  more  recent  times  that  the 
marked  reaction  has  come  against  the  employment  of  anything  other 
than  structures  of  an  autoplastic  nature  in  the  process  of  surgical 
reconstruction. 

All  of  us,  who  have  embedded  Lane's  plates,  or  other  nonyielding 
foreign  substances,  know  perfectly  well  what  an  extensive  bone  atro- 
phy takes  place  in  their  vicinity.  The  same  thing  holds  good,  in  a 
lesser  degree  of  wire  sutures,  and  all  the  other  multitude  of  non- 
yielding  foreign  bodies,  which  have  from  time  to  time  been  employed 
with  design.  Indeed,  the  greater  majority  of  surgeons,  the  writer  in- 
cluded, go  so  far  as  to  shun  the  use  of  permanent  suture  material  of 
any  kind  in  a  region  from  which  it  can  not  be  readily  removed,  either 
by  nature  or  the  human  hand. 

It  is  with  no  little  chagrin  that  a  surgeon  confesses  to  having  left 
foreign  bodies  in  the  peritoneal  cavity  by  accident,  and  when  one 
realizes  that  such  case  reports  are  not  published  voluntarily  in  a 
majority  of  instances,  he  is  prone  to  conclude  that  the  accident  is  far 
more  common  than  we  have  usually  supposed.  No  doubt,  many  an 
individual  has  lost  his  life  in  consequence  of  this  accident,  hence, 
the  number  of  reported  instances  grows  relatively  less  in  the  light  of 
such  reasoning. 

Neugebauer1  has  done  more  than  any  other  writer  to  attract  the  at- 
tention of  the  profession  to  this  matter.  His  study  of  it  came  about 
as  a  result  of  his  being  called  upon  to  make  statistical  studies,  which 
were  used  in  the  defense  of  two  brother  physicians,  who  were  accused 
of  this  dereliction.  The  case  in  question  is  so  instructive,  and  in 
many  respects  so  dramatic,  that  it  is  quoted  in  some  detail  by  ex- 
cerpts taken  from  Schachner2  (whose  article  is  worthy  of  complete 
perusal  by  those  especially  interested  in  this  subject). 

175 


176  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

"Professor  Kosinski  performed  an  abdominal  seetion  upon  a  pa- 
tient fifty  years  of  age,  for  an  ovarian  cystoma  with  a  twisted  pedi- 
cle. The  operation  was  very  difficult  on  account  of  numerous  ad- 
hesions and  an  interrupted  narcosis. 

"After  the  first  few  days  an  elevation  of  temperature  occurred, 
accompanied  with  abdominal  pains  and  pains  in  one  leg.  An  in- 
flammatory infiltrate  was  felt.  By  this  time  it  was  discovered  that 
two  artery  clamps  were  missing  from  the  instrument  cabinet.  It 
was  thought  that  the  artery  clamps  might  have  been  taken  by  Dr. 
Solomon,  as  he  had  left  shortly  after  this  operation  to  perform  an- 
other in  one  of  the  provinces.  Nevertheless,  the  coincidence  aroused 
the  suspicion  of  Dr.  Kosinski.  that  perhaps  the  missing  clamps  had 
been  left  in  the  abdomen. 

"Consequently,  six  weeks  after  the  laparotomy,  he  reopened  the 
abdomen  to  investigate  the  infiltration,  but  found  neither  pus  nor  the 
missing  clamps.  His  suspicions  were  not  allayed.  However,  he  con- 
cluded to  wait  for  further  developments.  The  condition  improved 
after  the  second  abdominal  section,  although  there  remained  a  fistula, 
which  finally  closed. 

"Several  weeks  passed,  but  as  the  convalescence  seemed  to  be  re- 
larded.  I))'.  Kosinski  was  again  called  for  a  more  thorough  examina- 
tion. On  this  occasion,  he  felt  a  hard  resistance  in  the  region  of  the 
umbilicus.  Per  rectum  and  per  vagina  there  was  nothing  to  be  felt. 
His  former  suspicions  were  renewed,  and  he  expressed  them  to  the 
family,  stating  thai  perhaps  the  hemostats  that  were  missing  from 
the  cabinet  had  been  left  in  the  abdominal  cavity. 

"Professor  Kosinski  insisted  that  another  operation  be  undertaken 
and  offered  to  perform  the  same  gratis.  The  patient  had  agreed  and 
a  room  had  been  prepared  for  her,  but  she  failed  to  appear.  The 
family  physician  had  informed  her  two  sons  of  the  nature  of  the  op- 
eration, to  which  they  failed  to  give  their  consent,  as  they  stated  they 
had   lost   all  confidence  in  Professor   Kosinski. 

"Tlie  patient  was  sent  to  the  health  resort.  Ciechocinek,  with  the 
view  of  promoting  the  absorption  of  the  inflammatory  exudate.  She 
improved  to  such  an  extent  thai  when  her  sons  told  her  of  the  sus- 
picion of  Dr.  Kosinski,  she  would  not  believe  it  and  ridiculed  the 
idea. 

"Six  months  after  the  first  operation,  the  patient  arrived  at  War- 
saw from  Ciechocinek.  Before  the  arrival  at  the  station,  she  reached 
up  to  get  some  baggage,  and  at  the  same  moment,  suddenly  became 
faint.  The  momentary  shock  soon  passed  and  on  reaching  home, 
she  entertained  her  sons  until  late  ;it  night.     On  the  following  morn- 


FOREIGN   BODIES   LOST   IN    THE   PERITONEAL    CAVITY  177 

ing,  she  felt  extremely  weak,  and  Dr.  Frankel  was  called  in,  who  de- 
manded immediate  operation  by  Professor  Kosinski,  and  told  her  sons 
that  no  time  should  be  lost.  They  refused  to  call  Dr.  Kosinski,  but 
called  in  Professor  Wassiljew.  The  latter  saw  the  exhausted  pa- 
tient about  midday,  and  was  told  of  the  suspicion  of  Dr.  Kosinski. 
In  spite  of  the  fact  that  the  patient  had  passed  by  rectum  in  all,  a 
vessel  full  of  blood  clots,  the  professor  suggested  that  a  radiogram 
be  made,  and  the  patient  was  removed  in  a  clrosky  to  an  infirmary, 
where  she  was  led  up  three  steps  and  remained  several  hours.  Several 
radiograms  were  made,  but  with  negative  results.  The  exhausted 
patient  was  taken  to  her  home  late  at  night,  and  the  following  morn- 
ing, Dr.  Wassiljew,  assisted  by  Dr.  Krejewski,  performed  the  abdom- 
inal section.  Partial  narcosis  was  used,  and  the  patient  became  al- 
most pulseless.  The  Douglas  pouch  was  found  covered  by  inflamma- 
tory bands.  A  second  oblique  incision  was  made  above  Poupart's 
ligament,  hoping  to  reach  the  seat  of  disturbance  extraperitoneally. 
A  large  cavity  was  opened,  in  which  both  hemostats  were  discovered, 
lying  parallel  and  just  above  the  pelvic  brim.  Both  forceps  had 
forced  an  entry  into  the  left  external  iliac  artery.  The  removal  of  the 
forceps  was  attended  with  a  furious  hemorrhage,  which  1he  operator 
endeavored  to  control  by  compressing  the  aorta.  The  cavity  was 
tamponed.     The  patient  died  upon  the  table. 

"The  ends  of  the  forceps  had  punctured  the  left  external  iliac 
artery,  when  the  patient  reached  up  to  get  her  baggage  at  the  rail- 
way station.  A  false  traumatic  aneursym  had  ensued  as  the  autopsy 
showed.  The  lower  end  of  the  forceps  had  perforated  the  large  in- 
testine and  this  accounted  for  the  blood  passing  from  the  injured  ar- 
tery by  way  of  the  rectum.  Had  the  operation  been  performed  when 
the  patient  left  the  railway  carriage,  or  even  on  the  following  morn- 
ing as  the  family  physician  had  requested,  perhaps  there  would  have 
been  a  recovery. 

"The  patient,  who  was  suffering  from  an  injured  artery,  was  driven 
in  a  carriage  to  her  home ;  from  there  to  an  infirmary,  then  marched 
up  three  steps  to  have  a  radioscopic  examination  made,  with  un- 
satisfactory result,  as  it  appears,  owing  to  imperfections  in  connec- 
tion with  the  outfit.  After  the  unsuccessful  attempt,  another  twenty 
hours  had  elapsed  before  the  operation  was  performed. 

"The  trial  lasted  four  days.  There  were  six  experts,  two  who  had 
made  the  postmortem  examination,  to  judge  the  pathological-anatom- 
ical side. 

"Neugebauer  supplied  the  statistics  that  were  likely  to  be  called 
for  in  the  controversy.    Professor  Pawlow,  of  St.  Petersburg,  under- 


178  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

took  ti>  depict  what  is  called  a  coeliotomy,  and  the  complications  and 
mistakes  that  are  likely  to  occur. 

''Summary: — The  direct  cause  of  death  in  this  case  was  the  per- 
foration of  the  artery  by  means  of  the  foreign  body.  The  indirect 
cause,  the  refusal  of  the  sons  to  comply  with  the  request  for  another 
abdominal  section  by  Dr.  Kosinski;  and  the  loss  of  time  that  arose 
from  the  trip  to  Cieehocinek.  The  trial  ended  in  the  acquittal  of  the 
accused." 

A  rather  striking  instance  of  a  similar  nature  occurred  many  years 
since,  in  the  practice  of  a  distinguished  St.  Louis  surgeon.  He  had 
operated  on  a  gentleman,  who  had  left  the  hospital  in  a  reasonably 
good  condition,  and  not  having  reported  since  that  time,  his  satisfac- 
tory convalescence  had  been  taken  as  a  matter  of  course. 

A  few  months  later,  the  surgeon  was  in  his  office  one  day,  when 
tli is  patient  walked  in.  presented  an  artery  forceps,  with  the  inquiry. 
"■  Is  this  yours  .'" 

"Of  course  it  is.  it  has  my  private  mark  on  it."  replied  the  surgeon. 

'"That  is  all  I  wish  to  know,*'  the  patient  said.  ''It  was  taken 
from  my  abdomen  some  months  after  I  left  your  service." 

In  order  that  there  might  be  no  misunderstanding  of  the  patient's 
intent,  he  had  brought  along  his  legal  adviser  for  the  interview,  which 
did  not  end  until  a  financial  arrangement  had  been  consummated,  of 
a  nature  so  satisfactory  to  all  concerned,  that  the  incident  never  found 
its  way  into  court. 

I  was  consulted  not  long  since  by  a  gentleman  who  had  an  inter- 
mittent biliary  fistula.  He  gave  a  history  of  two  surgical  operations; 
at  the  first  one  gallstones  had  been  removed,  although  neither  pro- 
cedure had  succeeded  in  relieving  him  of  his  symptoms.  He  was  not 
exactly  sure  what  had  been  done,  nor  could  we  get  the  technical  de- 
tails of  thr  previous  operations,  since  my  confrere  had  permanently 
left  St.  Louis. 

Upon  opening  the  abdomen,  a  large  gauze  pad  was  found,  occupy- 
ing a  space  between  the  stomach,  colon,  and  under  surface  of  the  liver, 
a  site  which  the  gall  bladder  must  have  formerly  occupied,  and  into 
which  bile  was  welling  up  from  below,  there  being  a  communication 
with  one  of  the  ducts.  The  patient  stated  that  his  second  operation 
had  been  of  a  minor  character,  and  had  not  at  all  modified  the  course 
of  his  malady,  and  it  "had  seemed  unsatisfactory  to  the  operator, 
hence,  one  is  prone  to  speculate  on  tiie  interesting  probability  of  the 
surgeon  having  left  the  gauze  pad  at  his  first  operation,  and  totally 
overlooked  it  during  the  second  performance.     It  must  he  very  rarely 


FOREIGN  BODIES  LOST  IN  THE  PERITONEAL  CAVITY        179 

the  ease  that  a  foreign  body  left  at  a  first  sitting  is  not  removed  at 
the  second. 

I  remember  very  well  the  first  time  I  ever  detected  a  foreign  body 
which  had  been  left  in  the  abdomen  by  accident.  A  colleague  re- 
quested me  to  explore  one  of  his  patients  for  a  very  ill-defined  symp- 
tom-complex, which  had  followed  an  operation  on  the  pelvic  viscera. 
We  were  both  surprised,  and  my  colleague  greatly  embarrassed,  by 
finding  a  very  large  gauze  pad,  tightly  encapsulated  between  intes- 
tinal coils.  The  interesting  thing  about  this  case,  and  the  reason  for 
quoting  it  is  that  it  exemplifies  in  no  uncertain  way,  nature's  method 
of  spontaneous  relief,  which  must  be  rather  frequently  afforded  such 
patients.  There  was  no  mistaking  the  fact  that  one  corner  of  the 
thick  gauze  pad  was  drawn  out  and  twisted  into  a  conical  mass,  of 
which  the  distal  six  or  eight  centimeters  were  smeared  with  feces. 
Upon  further  inspection  of  the  wound,  we  found  that  this  gauze  cone 
had  been  withdrawn  from  an  opening  in  the  intestine  into  the  lumen 
of  which  viscus,  the  gauze  was  gradually  being  drawn  by  peristaltic 
activity.  No  doubt,  in  the  course  of  time,  the  newly  formed  cavity, 
in  which  the  pad  lay,  would  have  been  emptied  and  its  walls  collapsed  ; 
then  had  the  foreign  body  not  obstructed  the  intestine,  it  would  have 
eventually  been  passed  out  the  anus,  and  quite  possibly,  never  been 
noted  at  all  by  the  patient. 

To  one  unfamiliar  with  the  subject,  this  may  serve  as  a  striking 
example  of  the  fact  that  nature  is  sometimes  more  generous  to  us 
than  we  have  deserved,  in  the  after-treatment  of  surgical  patients. 

Almost  any  surgeon  of  experience  has  had  his  attention  attracted 
to  these  cases,  but  no  doubt,  all  of  us  will  be  surprised  to  read  for 
the  first  time,  that  Neugebauer3  claimed  that  in  1907  he  had  collected 
236  authentic  records  of  this  sort.  More  recently,  Crossen4  published 
a  list  of  240  such  cases,  and  he  surprised  us  all  the  more  when  he 
stated  that  about  one-fourth  of  these  individuals  died  as  a  result  of 
these  accidents.  As  most  of  us  would  suppose,  from  our  limited  ex- 
periences, a  gauze  sponge  was  the  article  most  frequently  left  behind, 
although  the  offending  matter  was  a  forceps  (Fig.  27),  or  some  part 
of  another  instrument  in  about  one-fourth  of  all  such  reported  in- 
stances. 

It  must  be  that  parts  of  needles  are  very  commonly  lost  in  the 
peritoneal  cavity.  All  those  who  have  had  experience  deep  in  the  pel- 
vis, know  that  needles  not  infrequently  break,  and  occurring  as  it  does, 
when  a  part  of  this  small  instrument  is  imbedded  in  the  tissues,  one 
readily  understands  that  a  fragment  is  recovered  with  the  greatest 
difficulty. 


180  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

I  know  a  number  of  operators  who  have  had  this  unfortunate  ca- 
lamity to  befall  them,  and  I  do  not  recollect  one  who  is  given  to  care- 
less practices,  hence,  it  must  be  that  this  accident  is  rarely  the  result 
of  carelessness,  or  to  a  lack  of  some  system,  calculated  to  prevent  just 
such  happenings.  One  is,  therefore,  prone  to  analyze  the  various  in- 
stances in  which  the  accident  has  taken  place,  and  if  possible,  to  for- 
mulate some  general  rules  which  may  call  attention  to  the  reasons 
they  occur. 

In  one  case,  extreme  hasti  seemed  necessary  in  the  removal  of  a 
gangrenous,  perforated  gall  bladder,  to  the  end  that  gauze  packing 
was  placed  and  supposedly  removed,  with  consideration  for  only  one 
prime  necessity :  viz.,  that  the  patient  must  be  returned  to  bed  be- 
fore it  was  too  late.    In  this  instance,  a  gauze  pack  was  left  behind 


rig.  27. — Rusty  oved  from  abdomen  at  a  remote  period.      (After  Keen). 

and  removed  some  months  later,  so  it  will  be  noted  that  foreign  bodies 
are  likely  to  be  lost  in  those  operations  attended  with  rather  unusual 
haste. 

In  another  instance,  a  furious  h<  ihoitIi<i</<  from  an  unseen  cause. 
complicated  a  splenectomy,  and  several  packs  were  thrust  into  the 
cavity  from  which  the  blood  came,  the  field  being  more  or  less  ob- 
scured by  it.  rflie  abdomen  was  hastily  closed,  and  when  all  packs 
were  removed  a  few  days  later,  one  was  accidentally  left  behind,  pro- 
ducing a  decubitis  of  the  stomach  wall,  and  a  gastric  fistula,  which 
resulted  in  the  starvation  of  the  unhappy  individual,  it  will  be  seen, 
therefore,  that  hemorrhage  is  another  of  the  factors  which  may  lead 
to  this  undesirable  accident. 

It  may  he  mentioned  in  this  connection  that  men  who  work  in  a 
large  number  of  hospitals  are  more  likely  to  expose  their  patients  to 
this  accident    than   are  those  who   follow   the  single  routine,  which    is 


FOREIGN  BODIES  LOST  IN  THE  PERITONEAL  CAVITY        181 

possible  under  one  roof.  Every  hospital  has  its  particular  plan  for 
avoiding  this  mishap,  and  every  operator  must,  as  a  matter  of  course, 
conform  to  it,  hence,  the  conclusion  is  obvious  that  a  man  who  works 
in  many  hospitals  and  employs  many  methods,  some  of  them  at  rare 
intervals,  is  particularly  likely  to  experience  this  accident. 

It  must  be  noted  in  passing,  that  foreign  bodies  found  in  the  ab- 
dominal cavity  do  not  necessarily  mean  that  some  surgeon  is  to 
blame.  Green5  reported  a  case  in  which  a  bone  crochet  hook,  4% 
inches  long,  was  found  at  operation  within  the  layers  of  the  mesen- 
tery of  the  colon.  The  patient,  eleven  days  before,  had  inserted  this 
instrument  into  the  uterine  cavity,  in  an  effort  to  induce  menstrual 
flow,  and  during  the  effort  had  lost  it.  The  symptoms  were  nil  save 
for  slight  pain  when  she  moved.  The  hook  had  evidently  penetrated 
the  soft  uterine  wall.  Schachner6  also  reports  a  case  in  which  gauze 
was  found  to  have  been  discharged  through  an  abdominal  abscess. 
The  woman  was  insane  and  had  been  in  the  habit  of  swallowing  strips 
of  cloth.  Xo  previous  operation  had  been  performed  and  it  was 
thought  that  the  cloth  had  ulcerated  through  the  wall  of  the  stomach. 

The  Final  Disposition  of  foreign  bodies  in  the  peritoneal  cavity  has 
been  referred  to  in  one  case  of  the  author,  where  extrusion  into  the 
intestine  was  found  in  progress.  This  is  probably  the  most  common 
fate  of  all  such  bodies,  provided  the  individual  lives  long  enough  for 
its  accomplishment,  and  no  secondary  laparotomy  be  attempted.  We 
can  imagine  certain  absorbable  substances,  which  are  eventually  taken 
care  of  by  phagocytic  action.  In  other  instances,  the  suppurative 
and  destructive  process  may  become  so  extensive  that  a  foreign  body 
is  extruded  through  the  abdominal  wound,  or  if  it  has  firmly  healed, 
the  offending  mass  is  forced  out  of  the  abdomen  through  the  segment 
of  the  abdominal  wall,  which  offers  the  least  amount  of  resistance  to 
its  passage.  In  other  cases,  pointing  into  the  vagina  has  been  re- 
ported, and  in  at  least  one  reported  case,  a  forceps  found  its  way  into 
the  patient's  urinary  bladder. 

Symptoms. — The  symptoms  of  foreign  bodies  in  the  abdomen  are 
indeed  varied,  and  frequently  simulate  other  conditions.  There  may 
be  none  at  all.  and  aa'ain.  the  most  violent  intraabdominal  disturb- 
ances may  follow.  Much  depends  upon  the  character  of  the  object, 
its  location,  and  the  resistance  of  the  individual,  in  addition  to  the  all 
important  point  of  asepsis  mentioned  in  the  foregoing. 

The  reason  for  a  second  abdominal  section  is  usually  a  persistent 
fistula,  but  it  may  be  brought  about  by  symptoms  which  threaten  the 
life  of  the  patient.  The  foreign  body  may  cause  a  dull,  aching  pain 
which  is  constant,  and  more  or  less  localized.      The  presence  of  a  tu- 


182  AFTER-TREATMEXT    OF    SURGICAL    PATIEXTS 

mor,  at  times  freely  movable,  which  in  outline  resembles  the  foreign 
object,  may  be  seen.  The  peristalsis  is  apt  to  be  much  disturbed,  and 
the  whole  clinical  picture  may  be  that  of  intestinal  obstruction.  As 
mentioned  before,  a  violent  sepsis  may  quickly  develop,  or  as  Schach- 
ner7  has  aptly  said:  '"The  case  may  drag  along  with  symptoms  of 
more  or  less  pain,  or  a  sense  of  uneasiness,  elevation  of  temperature, 
emaciation,  sweats,  and  in  fact,  the  usual  course  of  a  mild  but  pro- 
tracted form  of  sepsis." 

The  symptoms  alone  are  not  a  safe  guide  in  these  cases,  and  in 
every  instance  they  must  be  backed  with  thorough  physical  examina- 
tions. In  many  cases,  the  objects  were  palpated  through  the  rectum, 
vagina,  and  through  the  abdominal  wall.  The  x-ray  is  valuable,  al- 
though in  Kosinski's  case,  the  instruments  did  not  show,  due  to 
faulty  technic. 

Pelvic  or  abdominal  abscesses,  and  fistula1  which  can  not  be  ex- 
plained, should  be  looked  upon  with  suspicion,  and  special  attention 
given  to  the  possibility  of  a  foreign  body.  Such  cases  require  diplo- 
matic handling,  and  no  word  or  expression  should  ever  reach  the  pa- 
tient, which  would  in  any  way  communicate  the  surgeon's  suspicions 
to  her. 

Prognosis. — The  prognosis  in  these  instances  varies  greatly  with 
the  character  of  the  foreign  body  left,  the  locality  in  which  it  lies, 
the  resists  nee  of  the  patient,  and  the  incidence  of  early  diagnosis. 
It  is  quite  probable  that  a  yielding  substance,  like  a  small  gauze  pad, 
may  lie  undisturbed  for  many  years,  provided  only  that  the  cavity  in 
which  it  becomes  walled  off  by  connective  tissue,  has  adequate  drain- 
age into  a  viscus  or  onto  the  surface.  Of  course  perforation  of  an 
important  hollow  viscera,  to  which  reference  has  been  made  in  the  pre- 
ceding paragraphs,  is  by  no  means  innocuous;  then  again,  there  is  no 
telling  when  an  unyielding  foreign  body  may  cause  perforation  of  a 
large  blood  vessel,  with  consequent  fatal  hemorrhage,  hence  it  will  be 
seen  that  prognosis  is  an  individual  matter  to  be  determined  in  each 
ease  on  its  individual  merits. 

Prevention.— Prevention  is  the  watchword  in  this  connection.  One 
of  the  earliest  means  of  preventing  this  accident  was  to  place  a  num- 
ber in  a  prominent  place  on  the  sponge  going  into  the  abdomen.  In 
1900,  Kelly8  devised  a  sort  of  a  metal  rack  for  these  objects,  but  in 
common  with  every  one  else,  gave  it  up  before  he  had  used  it  very 
long.  Fisher''  employed  a  tape  about  four  feet  Long,  on  which  a 
heavy  needle  was  threaded.  As  each  sponge  was  put  to  use,  the  needle 
was  passed  through  it.  and  thus  all  the  sponges  threaded  on  the  tape. 
<  arson,10  of  St.  Louis,  used  to  attach  to  the  corner  of  his  packs,  metal 


FOREIGN    BODIES    LOST    IN    THE    PERITONEAL    CAVITY  183 

rings  so  large  that  they  could  hardly  escape  attention  and  be  carried 
into  the  abdomen.  Others  have  used  large  rolls  of  gauze  in  packing 
off,  large  portions  of  the  material  being  left  outside  of  the  cavity,  in 
an  effort  to  prevent  the  loss  of  that  which  was  employed  within  it. 
At  one  time,  simple  counting  of  all  gauze  packs  was  rather  frequently 
resorted  to,  although  this  can  not  be  said  to  have  been  a  marked 
success.  In  more  than  one  instance  a  miscount  has  been  reported 
after  closure  of  the  abdomen,  then  a  reopening  made  and  a  fruitless 
search,  after  which,  the  supposedly  buried  pad  has  been  found  on 
the  operating  room  floor. 

A  surgeon  in  one  of  our  St.  Louis  hospitals,  hoping  to  obviate  the 
danger  under  discussion,  formed  the  habit  of  employing  large  towels 
for  the  purpose  of  packing  off  hollow  viscera,  but  he  gave  this  up 
after  returning  to  the  hospital,  following  an  absence  of  several  days, 
to  learn  that  his  house  surgeon  had  relieved  a  case  of  intestinal  ob- 
struction by  removing  one  of  these  towels  some  days  after  the  orig- 
inal operation. 

A  most  reasonable  proposition  in  this  connection  is  to  employ  a 
very  long  strip  of  dental  rubber  dam  for  abdominal  wounds.  This 
could  hardly  be  overlooked  and  lost,  especially  if  a  generous  supply 
of  it  were  left  outside  the  peritoneal  cavity  and  anchored  to  the  table 
coverings. 

Crossen11  uses  a  ten-foot  continuous  roll  of  gauze,  25  mesh  to  the 
inch.  "Each  strip  is  packed  into  a  separate  cloth  bag,  five  inches 
wide  and  ten  inches  deep."  The  end  of  the  strip  which  is  introduced 
first  into  the  bag  is  sewed  securely  to  the  bottom.  To  this  region, 
also  is  attached  a  safety  pin  for  fastening  the  bag  to  the  sterile  sheet. 
An  apparatus  to  hold  both  wide  and  narrow  strips  is  described  by 
this  author  in  detail.  "From  48-inch  heavy  cluck,  a  piece  26  inches 
long  is  cut.  This  is  divided  in  half,  giving  two  pieces,  each  24  by  26 
inches.  Beginning  at  the  selvage  edge,  a  triangular  piece,  2  inches 
wide  at  the  top,  and  running  out  near  the  bottom,  is  cut  off  from 
each  end,  giving  the  pieces  shown  in  the  figure,  which  is  24  inches 
long,  26  inches  wide  at  the  lower  edge,  and  22  inches  wide  at  the  up- 
per edge.  The  lower  edge  is  hemmed,  giving  three  thicknesses.  This 
stiffens  the  edge,  the  piece  is  then  folded,  bottom  to  top,  and  the  raw 
ends  bound  with  tape  as  they  are  stitched  together  so  that  no  ravelings 
can  be  exposed.  The  front  edge  has  been  stiffened  by  the  hemming 
and  it  is  four  inches  longer  than  the  back  edge,  hence  the  bags  stay 
open.  It  is  next  stitched  down  the  middle,  so  as  to  form  two 
large  pockets.  Another  bag  is  then  made  just  like  the  first  one, 
except    that    one    of    the    large    pockets    is    stitched    down    to    the 


184  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

middle,  so  as  to  form  two  small  pockets.  The  two  bags  are  then 
fastened  together  with  2-inch  belting,  leaving  8  inches  between.  The 
end  of  a  narrow  strip  is  carried  to  the  bottom  of  a  narrow  pocket  and 
fastened  there,  as  indicated  by  the  black  stitch.  The  strip  is  then 
packed.  The  other  narrow  pocket  is  filled  in  the  same  way.  The 
wide  strip,  folded  as  in  the  figure,  is  laid  in  a  wide  pocket  of  the 
other  bag.    The  bags  are  then  sterilized." 

At  the  operation  following  the  placing  of  the  towels,  and  finally  the 
sterile  lap-sheet,  the  apparatus  as  above  described,  is  placed  over  all 
across  the  abdomen.  The  wide  strip  may  or  may  not  be  soaked  in 
sterile  salt  solution,  but  in  either  case,  it  is  fastened  to  one  of  the 
cross  straps  by  means  of  the  tapes  which  are  attached  to  the  end  of  the 
wide  strip  for  this  purpose.  No  strip,  under  any  circumstances,  is 
cut  or  detached,  the  soiled  portions  being  placed  in  the  opposite  side 
of  the  bag,  which  has  been  arranged  for  them.  The  first  case  of  a 
foreign  body  left  in  the  abdomen,  following  the  use  of  this  contriv- 
ance, is  yet  to  be  reported. 

The  method  which  I  have  employed  for  many  years  is  perhaps  the 
most  commonly  used,  and  has  at  least  in  its  favor  the  fact  that  almost 
every  one  is  familiar  with  the  method,  which  consists  in  the  use  of 
a  gauze  square,  to  the  corner  of  which  a  tape  has  been  firmly  sewed. 
this  latter  to  be  anchored  to  the  table  covering  by  a  heavy  forceps. 
Fortunately,  no  plan  of  packing  off  is  simpler  than  this,  but  it  has 
two  serious  objections  to  its  use.  (1)  All  forceps  will  be  found  to 
wear  in  the  catch  and  come  loose  at  the  least  expected  time.  (2) 
An  assistant  is  very  apt  to  remove  any  forceps  in  sight,  and  may 
therefore,  take  one  off  such  a  tape  when  the  supply  gets  short,  as  it 
does  in  smne  long-continued  operation,  or  when  a  sudden  need  pre- 
sents itself. 

My  own  conclusion  as  to  the  usefulness  of  a  method  is  simply  this: 
every  operator  finds  the  procedure  with  which  he  is  most  familiar  to 
suit  his  needs,  and  I  should,  therefore,  recommend  that  he  continue 
to  use  any  one  which  is  found  to  uive  him  immunity  from  the  accident 
under  discussion.  The  one  I  am  accustomed  to  suits  me  extremely 
well,  although  I  must  admit  that  many  a  man  in  whom  I  have  con- 
fidence, utterly  refuses  to  have  anything  to  do  with  it,  and  no  doubt 
he  is  right  according  to  his  lights.  It  must  he  stated,  before  closing 
the  paragraph  on  prevention,  that  no  means  at  our  command,  with 
possible  exception  of  the  one  devised  by  ( 'rossen.  has  prevented  this 
lamentable  happening,  and  if  it  be  true  that  history  repeats  itself, 
we  must  take  a  rather  somber  outlook,  so  far  as  this  phase  of  surgery 


FOREIGN  BODIES  LOST  IX  THE  PERITONEAL  CAVITY        185 

is  concerned,  and  neglect  no  precaution  which  is  within  the  field  of 
human  possibilities. 

Treatment. — The  treatment  of  foreign  bodies,  which  have  been 
accidentally  left  in  the  peritoneal  cavity,  consists,  of  course,  in  their 
removal  as  soon  as  discovered.  I  am  sure  no  one  would  hesitate  to  do 
this  before  the  patient  has  left  the  table,  at  the  original  procedure, 
provided  discovery  were  made  at  this  time.  The  matter  of  treatment, 
as  it  affects  the  special  viscera,  which  have  been  involved  in  the  nu- 
merous instances  cited,  must  be  left  for  a  consideration  special  for 
each  case. 

The  operative  technic  requires  for  its  successful  consummation, 
something  which  may,  for  want  of  a  better  term,  be  defined  as  intui- 
tion. The  surgeon,  who  has  once  removed  a  gauze  pad  from  a  wound 
will  never  forget  the  peculiar  tactile  sensation  this  imparted  to  the  ex- 
ploring finger.  Unfortunately,  it  can  not  be  described,  but  must  be 
acquired  by  practice.  To  confirm  the  finding,  tear  off  a  raveling 
with  a  forceps,  then  attract  the  attention  of  onlookers  to  something 
outside  the  window,  cover  the  field  with  a  towel,  and  proceed  to  de- 
liver the  offending  object. 

It  is  hardly  fair  to  surgery  that  this  subject  be  dismissed  without 
at  least  a  reference  to  the  malingering  which  is  possible  in  this  con- 
nection. Porter,12  from  whose  own  words  I  shall  quote  liberally,  gives 
an  interesting  example  of  a  type  of  patient  against  whom  the  surgeon 
must  be  constantly  on  guard. 

An  operation  had  been  performed  for  parovarian  cyst,  hydrosal- 
pinx and  chronic  appendicitis.  The  patient  had  been  discharged 
from  the  hospital  twenty-two  days  after  the  operation.  The  conva- 
lescence had  been  normal.  Porter,  after  eight  days,  was  informed  by 
the  family  doctor  that  he  had  removed  several  pieces  of  gauze  from 
her  vagina.  "Upon  inquiry  from  him,"  says  Porter,  "I  learned  that 
the  pieces  were  removed  with  forceps,  in  the  shape  of  rolls  about  the 
length  and  size  of  a  lead-pencil,  and  after  all  presenting  were  re- 
moved, others  would  present  in  a  few  hours,  and  he  thought  they  came 
through  an  opening  in  the  right  side  of  the  vagina,  about  the  size  of 
a  lead-pencil. 

"I  visited  the  patient  at  her  home  with  her  doctor,  and  was  shown 
a  large  number  of  pieces  of  different  textures,  whereupon,  I  remarked 
that  the  goods  were  not  such  as  I  used,  all  told,  in  the  operation,  and 
that  consequently  they  had  not  been  left  in  the  woman's  belly  by  me. 
It  was  averred  that  they  could  get  into  her  belly  only  through  the 
wound  made  by  me,  and  at  the  time  it  was  made,  because  it  had  been 
closed,  healed  by  first  intention,  and  was  still  closed.     The  patient 


186  AFTER-TREATMENT   OF    SURGICAL    PATIENTS 

facetiously  remarked  that  she  supposed  she  swallowed  them.  'No,'  I 
replied,  'had  you  swallowed  them,  they  would  not  come  out  through 
the  vagina.'  " 

"Dr.  F.  now  asked  the  patient  whether  she  thought  more  pieces  were 
coming  down,  and  being  answered  in  the  affirmative,  he  introduced 
a  speculum  and  found  that  she  was  right.  I  removed  the  speculum, 
and  introduced  my  finger,  which  came  upon  a  small  wad  of  some- 
thing, which  upon  removal,  proved  to  be  a  piece  of  ordinary  muslin 
about  three  inches  wide  by  seven  inches  long,  twisted  into  a  rope,  and 
doubled  upon  itself  so  as  to  make  a  small  ball  or  wad.  It  was  per- 
fectly clean  and  was  so  saturated  with  what  looked  and  smelled  like 
urine  that  on  squeezing  between  the  fingers,  several  drops  were 
squeezed  out.  I  examined  the  vagina  with  my  finger,  assuring  myself 
that  there  were  no  more  pieces  there,  that  there  was  no  hole  leading 
into  the  pelvic  cavity,  and  that,  in  fact,  it  was  a  perfectly  healthy 
vagina,  and  in  no  wise  unusual  except  its  cleanliness,  for  which,  of 
course,  the  frequent  wipings  it  received  were  accountable." 

In  regard  to  the  possible  cause  for  the  deception,  Dr.  Porter  men- 
tioned: 1.  Desire  for  money.  2.  Desire  for  sympathy.  3.  Desire  to 
avoid  work.     4.  Sexual  perversity. 

Full  credit  is  due  0.  F.  McKittrick  for  having  abstracted  all  the 
literature  to  which  reference  is  made  in  this  chapter. 

Bibliography 

iNeugebauer:     Zentralb.  f.  Chir.,  1900,  No.  3. 

-Srliaclmer:      Ann.    Surg.,   1901,  xxxiv,   514. 

aNeugebauer:     Arch.   f.  Gynak.,  lxxxii,   1907. 

*Crossen:      Am.  Jour.  Obst.,  1909,  lix,  58. 
t.ivcn:      Brit.  Med.  Jour.,  1912,  ii,  1747. 

•'•Sc-hachner :     Loe.  cit. 

■  Schaclmer:     Loe.  '-it. 

-Kelly:      New  York  Med.  Jour.,  March,  1910. 

sFisher:      Ann.   Surg.,   1903,  xxxviii.    778. 
10Carson:     Personal  communication. 
11Crossen:      Personal  communication. 
12Porter:      Jour.  Indiana  Med.  Assn.,  1908,  i,  131. 


CHAPTER  XXIII 
FISTULJE 

By  Willard  Bartlett,  St.  Louis,  Mo. 

A  fistula  is  an  artificial  channel  which  connects  a  gland,  duct  or 
viscus  with  another  one  of  these  three,  or  with  the  outer  world.  The 
importance  that  this  lesion  occupies  in  surgery  is  well  shown  by  the 
fact  that  the  Index  Medicus,  for  the  last  three  years,  listed  a  total  of 
sixty-six  varieties.  A  few  appeared  under  two  different  captions, 
however,  and  not  nearly  all  of  them  followed  surgical  operations, 
hence,  only  the  following  varieties  will  be  considered  at  this  time* 

Internal  fistulas  have  connected  up  the  viscera,  two  or  more  at  a 
time,  in  an  almost  inconceivable  variety  of  combinations,  while  the  ex- 
ternal variety  have  presented  surgical  problems  which  have,  in  some 
instances,  baffled  the  most  experienced  and  painstaking  operator. 

It  may  be  said  in  general  that  the  prognosis  of  a  fistula  is  governed 
by  several  considerations.  Perhaps  the  first  and  most  important  of 
these  is  obstruction  to  the  normal  outflow  of  material  which  is  escap- 
ing by  the  artificial  channel.  Every  surgeon  of  experience  has  drained 
an  obstructed  intestine  and  seen  the  artificial  fistula  remain  open  as 
long  as  needed,  and  then  close  spontaneously  as  soon  as  a  mechanical 
obstruction  lower  down  in  the  canal  was  overcome.  The  length  of  a 
fistula  has  very  much  to  do  with  its  spontaneous  closure.  A  short, 
wide  canal  gives  an  exceedingly  unfavorable  outlook,  while  a  long, 
narrow  one,  other  things  being  equal,  is  distinctly  more  likely  to  close 
of  its  own  accord.  The  mechanics  which  underlie  these  two  proba- 
bilities are  self-evident.  The  character  of  its  walls  has  much  to  do 
with  the  natural  obliteration  of  one  of  these  tubes.  It  stands  to  rea- 
son that  the  walls  of  a  rigid  tube  can  not  collapse  as  a  consequence 
of  pressure  from  the  outside,  therefore,  one  of  this  character  must 
often  be  excised  in  toto  before  anything  can  be  accomplished. 

Treatment. — Regarding  the  treatment  of  such  conditions,  it  may 
be  said  that  stimulation  by  chemical  or  mechanical  means  tends  to 
a  favorable  end.  Nitrate  of  silver,  Beck's  bismuth  paste,  and  many 
other  agents  which  come  under  the  former  heading,  have  given  ex- 
cellent results  in  isolated  instances.  This  presupposes,  of  course,  that 
there  is  no  obstruction  also  the  presence  of  no  foreign  body.  The  cu- 
rette has  played  a  very  important  role  in  the  mechanical  stimulation 

187 


188  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

of  these  canals,  while  an  ingenious  proposal  which  emanates  from  Dr. 
Hugh  H.  Young,1  is  the  introduction  into  a  bladder  fistula  of  a  screw 
in  the  ordinary  manner,  i.  e.,  by  rotating  it,  followed  by  direct  extrac- 
tion in  the  manner  one  draws  a  nail ;  it  is  attended  with  no  uncertain 
degree  of  stimulation. 

Before  any  form  of  surgical  operation  is  attempted,  it  is  good  policy 
here,  as  elsewhere  in  the  body,  to  improve  tissue  conditions  as  much 
as  possible.  If  a  thick-walled  fistulous  tract  is  to  be  excised,  and  is 
too  tortuous  to  be  threaded  onto  a  probe,  the  procedure  may  be  won- 
derfully facilitated  by  first  staining  the  canal  with  methylene  blue, 
after  which  it  is  not  at  all  likely  that  the  surgeon  will  lose  his  way. 

Digestive  Tract. — Fistula?  of  the  mouth  and  pharynx  have  occa- 
sionally been  produced  accidently  or  intentionally  after  the  removal 
of  the  various  tissues  which  enclose  these  cavities.  It  is  surprising 
to  see  how  quickly  and  how  satisfactorily  these  will  close  up,  or  at 
least  will  shrink  to  proportions  which  render  their  closure  a  matter 
of  simple  plastic  surgery.  A  due  regard  for  the  patient's  posture  en- 
ables feeding  to  be  continued  under  such  conditions,  especially  if 
liquids  be  given  through  a  tube  introduced  deeply  into  the  pharynx. 

Esophageal  fistula1  are  exceedingly  rare,  though  most  distressing 
when  they  do  occur.  They  are  highly  dangerous  on  account  of  the  loss 
of  food  which  is  inevitable.  I  know  of  a  combined  esophageal  and 
tracheal  fistula  being  caused  by  a  goiter  operation.  The  unfortunate 
patient  died  at  the  expiration  of  ten  days,  as  a  result  of  starvation 
and  exhaustion. 

A  consideration  of  stomach  fistula  brings  to  mind  the  fact  that  the 
most  common  internal  one  is  that  which  is  produced  by  pyloric  ob- 
struction, when  a  gastroenterostomy  is  made.  It  is  too  well  known 
to  merit  more  than  passing  mention  here. 

Hilgenreiner2  found  eight  postoperativi  stomach  fistula  described 
in  the  literature,  although  this  number  impresses  the  author  as  being 
ridiculously  low,  in  view  of  the  fad  that  he  alone  can  recall  three  of 
these  accidents.  He  thinks  the  prognosis  of  a  small  stomach  fistula  to  be 
very  good,  and  considers  spontaneous  recovery  by  the  patient  favored 
by  lying  on  the  back,  by  cauterization,  and  by  compression.  He  also 
thinks  that  the  best  operative  treatment  is  gastrorraphy,  possibly 
in  connection  with  a  plastic  operation,  and  feels  that  every  case  should 
be  operated  on  unless  closure  ensues  within  a  short  time.  This  has 
nothing  to  do,  however,  with  cancer  cases  or  patients  affected  by 
serious  general  disease.  If  gastrorraphy  is  not  practical,  gastro- 
enterostomy or  jejunostomy  may  be  indicated. 


FISTULA  189 

The  writer  made  a  secondary  laparotomy  and  successfully  sutured 
a  gastric  fistula  which  had  resulted  from  the  presence  of  a  drain  tube 
in  too  close  proximity  to  a  gastroenterostomy  suture  line.  In  two 
other  instances  which  are  known  to  me,  the  patient's  condition  for- 
bade any  form  of  secondary  operation.  In  one  case,  the  pressure  of 
a  gauze  pack,  which  was  left  in  the  abdomen  for  a  period  of  several 
days,  resulted  in  pressure  decubitis  and  the  formation  of  a  very 
large  gastric  fistula  which  rapidly  led  to  exhaustion  and  death.  In 
another  patient,  a  highly  anemic  young  woman  suffering  from  pyloric 
ulcer,  a  part  of  the  gastroenterostomy  suture  line  gave  way  eight 
days  after  the  operation,  and  though  the  patient  lived  more  than  a 
month,  still  there  never  seemed  to  be  a  time  when  a  secondary  opera- 
tion presented  any  possibility  of  being  successful  in  stopping  the  leak. 

Intestine. — The  lesions  which  come  under  this  heading,  may  be 
classified  as  accidental  and  intentional.  The  latter  are  made  for  the 
purpose  of  feeding  the  patient,  rather  frequently,  in  which  case,  the 
upper  portion  of  the  jejunum  is  chosen  and  a  tube  sewed  into  it,  after 
one  of  several  well-recognized  methods.  I  have  done  this  often,  al- 
though it  must  be  admitted  that  in  malignant  diseases  of  the  digestive 
tube  higher  up,  the  results  have  been  far  from  stimulating. 

Fistuke  have  been  rarely  employed  for  therapeutic  purposes,  es- 
pecially in  diseases  of  the  large  bowel,  antiseptic  and  other  fluids 
having  been  more  frequently  introduced  through  a  patent  appendix 
anchored  in  the  abdominal  wounds,  than  through  a  small  fistula 
established  somewhere  in  this  vicinity. 

Perhaps  the  most  frequent  of  the  fistulse  which  may  be  classed  as 
intestinal,  are  those  made  to  drain  obstructed  intestinal  coils,  under 
certain  circumstances:  viz.,  when  the  patient's  vitality  is  low  and 
when  at  the  same  time  it  can  be  shown  that  there  is  no  nutritional 
change  in  the  intestinal  wall.  This  procedure  may  attain  life  saving 
value.  I  happen  to  have  in  the  hospital  at  this  time,  two  patients 
who  furnish  examples  in  point,  and  show  how  radically  different  such 
fistulas  may  functionate  under  various  circumstances.  A  young 
woman  became  obstructed  from  pelvic  peritonitis,  and  as  a  last  resort, 
had  a  small  fistula  made  under  local  anesthesia.  She  immediately 
improved  under  drainage,  and  after  a  few  weeks,  began  to  have  nor- 
mal bowel  movements,  whereupon  her  fistula  promptly  closed  spon- 
taneously. The  second  patient  referred  to,  an  elderly  gentleman, 
suffering  from  carcinoma  of  the  rectum,  was  sent  into  the  hospital, 
completely  obstructed.  A  wholly  similar  fistula  was  made,  and  has 
continued  to  functionate,  since  there  has  been  no  let-up  in  the  obstruc- 


190  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

tion;   secondary   exploration   of   the   abdomen   lias   shown    general- 
ized peritoneal  carcinosis,  naturally  an  inoperable  condition. 

In  rare  instances,  a  life  has  been  saved  by  the  spontaneous  appear- 
ance of  a  fecal  fistula  in  appendicitis  attended  with  dynamic  obstruc- 
tion. Not  only  has  one  often  appeared  several  days  after  an  appen- 
dectomy, but  in  an  instance  which  recently  came  under  my  notice, 
one  followed  an  incision  made  in  the  treatment  of  a  phlegmon  of  the 
abdominal  wall.  It  was  noticed  that  with  the  escaping  of  gas  and 
fluid  feces,  there  was  immediate  relief  of  the  symptoms — this  was  in 
a  condition  which  seemed  to  threaten  life. 

Among  the  most  common  causes  of  postoperative  intestinal  fistula' 
are  the  ligation  of  nutrient  vessels,  imperfect  intestinal  suture  and 
strangulation  by  sutures,  appendectomy  with  improper  stump  treat- 
ment, the  leaving  behind  of  a  gangrenous  perforated  appendix 
and  pressure  necrosis  of  packs,  tubes  or  other  foreign  bodies. 
The  colon  has  been  frequently  wounded  in  the  course  of  a 
nephrectomy  or  salpingectomy,  while  intestinal  suture  in  the  course 
of  a  peritoneal  tuberculosis  is  exceedingly  likely  to  be  followed  by 
fecal  fistula.  Many  a  strangulated  hernia  operation  has  terminated 
with  the  establishment  of  a  fecal  fistula,  and  no  doubt,  lives  been 
saved  thereby.  One  of  the  most  common  injuries  of  the  duodenum 
results  from  the  removal  of  an  adherent  gall  bladder.  There  are 
other  isolated  causes  of  fecal  fistuhe,  but  one  of  the  foregointr  ac- 
cidents is  very  likely  to  be  at  fault. 

The  location  of  a  fecal  fistula  may  he  determined  with  a  fair  degree 
of  accuracy  in  many  ways.  The  character  of  the  discharge  will  aid 
one  in  determining  the  matter.  If  it  is  thick,  it  comes  from  low  down 
in  the  tube,  as  is  also  true  if  it  has  a  pronounced  odor.  Very  little 
gas  is  formed  high  up,  hence  this  is  a  matter  of  import.  The  presence 
of  bile  in  large  quantities  indicates  a  lesion  in  the  upper  small  bowel, 
as  may  be  also  said  of  the  presence  of  undigested  muscle  fibers. 
Methylene  blue  given  by  mouth  will  appear  unchanged  in  a  fecal 
fistula.  If  an  enema  appears  promptly  in  a  fecal  fistula,  the  surgeon 
can  be  fairly  sure  that  the  colon  is  affected,  since  under  normal  cir- 
cumstances, no  water  passes  backward  through  the  ileocecal  valve. 
Some  authors  have  thought  that  the  temperature  at  which  ice  cream  or 
other  cold  foods  appeared,  was  of  value  in  settling  this  problem. 
Many  observers  have  attempted  to  measure  the  exact  distance  of  the 
fistula  from  the  teeth,  by  feeding  the  patient  an  insoluble  and  un- 
digestible  substance  attached  to  a  string,  and  awaiting  the  appear- 
ance of  this  body  in  the  fistula. 


FISTULA 


191 


The  prognosis  of  a  fecal  fistula  is  modified  in  many  ways.  If  it  is 
very  high  up,  the  patient  may  rapidly  succumb  to  exhaustion,  unless 
operative  measures  are  attended  with  success.  It  is  almost  impossible 
to  say  whether  or  not  a  fistula  will  close  spontaneously.  This  depends 
upon  many  factors,  of  which  the  most  important  by  far,  is  obstruction 
lower  down.  A  spur  in  the  intestine  at  the  site  of  a  fistula  is  very 
likely  to  prevent  the  passage  of  intestinal  contents  in  the  normal  di- 
rection, beyond  its  site,  and  is.  therefore,  of  very  bad  prognostic  sig- 
nificance. This  is.  however,  most  easily  overcome  by  inserting  one 
blade  of  a  forceps  into  the  bowel  on  either  side  of  the  septum  and 
crushing  through  it.  A  completely  divided  gut  furnishes  the  most 
intractable  kind  of  fistula,  not  only  as  to  likelihood  of  closure,  but 
because  emptying  is  interfered  with  as  progressive  narrowing  of  the 
lumen  takes  place  and  obstruction  complicates  the  existing  conditions. 
In  addition  to  this,  there  is  a  great  tendency  for  the  distal  portion 
to  retract  away  from  the  wound  in  the  abdominal  wall.  and.  as  time 
goes  on,  for  this  entire  segment  to  become  atrophic :  in  fact,  this  may 
progress  to  such  an  extent,  in  the  course  of  years,  that  the  bowel 
comes  to  resemble  a  fibrous  cord,  and  because  of  the  complete  disap- 
pearance of  the  mucous  membrane,  can  after  the  lapse  of  sufficient 
time,  never  be  restored  to  function,  even  though  the  continuity  of  the 
tract  be  reestablished. 

Several  of  the  secondary  pathologic  changes  which  complete  the 
formation  of  a  fecal  fistula  were  called  to  mind  by  a  case  which  I  was 
recently  successful  in  operating  upon,  at  what  was  for  the  patient,  the 
eighth  sitting.  The  bowel  had  been  injured  during  some  pelvic  man- 
ipulation, and  then  six  attempts  made  to  close  the  opening  without 
success,  so  that  when  she  came  into  my  hands,  the  following  perplex- 
ing, though  interesting,  conditions  presented  themselves. 

The  ileum  was  completely  divided  and  the  upper  end  almost  closed 
as  a  result  of  cicatricial  contraction.  A  portion  seemed  to  be  missing. 
due  to  the  fact  that  the  lower  segment  had  retracted  to  a  considerable 
degree.  This  latter  appeared  to  be  of  small  caliber,  but.  nevertheless, 
end-to-end  union  was  performed,  resulting  in  a  complete  success. 

Complications. — Prolapse  of  the  mucosa  through  a  large  opening 
may  attain  gigantic  proportions.  The  surface  is  likely  to  bleed  if 
touched,  may  be  exceedingly  tender,  .and  incarceration  with  sponta- 
neous amputation  of  it  is  not  unknown.  Such  a  prolapse  usually  di- 
lates the  opening  through  which  it  comes,  until  a  considerable  her- 
niation of  other  viscera  may  be  present  at  the  same  time. 

The  patient's  nerves  suffer  early  in  the  development  of  a  fecal 
fistula.     As  a  matter  of  course,  and  in  manv  instances  rightly,  the 


392  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

unhappy  individual  considers  himself  ostracized.     However,  I  knew 
of  one  man  who  conducted  a  high  grade  restaurant  for  a  long  time, 
in  which  he  served  patrons  who  were  unaware  of  his  distressing  coi 
dition. 

The  most  annoying  skin  affections  complicate  fecal  fistulas.  The 
higher  the  fistula,  the  more  true  this  is,  largely  on  account  of  the 
presence  of  pancreatic  juices  which  simply  digest  everything  with 
which  they  come  in  contact.  I  have  been  disappointed  in  the  use  of 
the  oily  substances  so  frequently  suggested  for  the  treatment  of  this 
condition,  but  have  been  uniformly  satisfied  with  the  use  of  a  full 
body  bath  wherever  obtainable.  One  patient  spent  about  one-half  of 
her  time  in  the  water  and  was  not  annoyed  in  the  least  as  long  as  she 
remained  in  the  tub.  Of  course,  provision  must  be  made  for  keeping 
the  water  at  body  temperature  and  protecting  the  patient  from  pres- 
sure decul litis,  by  the  use  of  rubber  rings  or  other  materials  having 
the  same  purpose  in  view.  The  feeding  of  large  amounts  of  sodium 
bicarbonate  and  other  alkaline  substances  was  found  beneficial  in  this 
same  case,  no  doubt  by  stimulating  the  secretion  of  an  excess  of  hy- 
drochloric acid,  which,  to  a  corresponding  extent,  neutralized  the 
alkalinity  of  the  pancreatic  juice,  and  thus  limited  its  digestive  power. 
I  have  nowhere  seen  this  advocated,  but  warmly  suggest  a  future 
trial  of  it. 

Tetanus  has  not  infrequently  complicated  operations  on  fecal  fis- 
tula?. This  is  natural  enough  when  one  remembers  that  the  intes- 
tinal tract  of  man,  as  well  as  of  the  lower  animals,  is  the  natural  habi- 
tat for  the  tetanus  germ,  hence  the  disease  may  occur  wherever  there 
is  fecal  soiling.  It  is  therefore  recommended  by  many  authorities, 
that  a  prophylactic  dose  of  anti-tetanic  serum  precede  any  opera- 
tive maneuver  intended  to  cure  fecal  fistula. 

The  prognosis  is  almost  uniformly  good  in  that  very  common  type 
of  fecal  fistula  winch  follows  the  removal  of  the  appendix  under  cir- 
cumstances which  prohibit  our  doing  more  than  merely  ligating  the 
stump  and  dropping  the  gut  back  with  a  drain  tied  to  it.  If  there  is 
Localized  peritonitis,  the  bowel  wall  is  too  thick  and  friable  to  admit 
of  suturing,  and  a  ligature  rapidly  cuts  through.  However,  the  fis- 
tula is  of  only  a  few  days  duration,  unless  nutritional  changes  have 
forced  us  to  ligate  well  up  onto  the  head  of  the  cecum,  so  that  a  very 
large  opening  results. 

The  treatment  of  fecal  fistulas  may  be  divided  into  (1)  prophylac- 
tic, (2)  conservative,  and  (3)  operative.  They  may  no  doubt  be 
prevented  in  many  instances  by  care  in  separating  adhesions,  con- 
serving the  blood  supply  of  the  bowel,  careful  suturing,  by  avoidance 


FISTULA  193 

of  contact  with  packs  or  drains  at  suture  lines,  and  by  the  very  ear- 
liest possible  removal  of  them  wherever  employed  in  the  abdomen. 

Fistulas  will  frequently  be  prevented  by  the  routine  removal  of  the 
appendix  in  pus  cases  where  there  is  not  an  absolute  lethal  contra- 
indication. 

Conservative  treatment  consists  largely  in  the  avoidance  of  cathar- 
tics, and  the  use  of  small  enemas  which  tend  to  create  peristalsis  be- 
low the  fistula,  as  well  as  in  the  giving  of  food  which  leaves  a  minimum 
of  residue.  To  this  may  be  added  plugging  or  pressure  approxima- 
tion of  the  outlet,  as  well  as  the  various  forms  of  stimulation  men- 
tioned in  the  beginning  of  this  chapter. 

The  operative  treatment  may  consist  of  simple  abdominal  wall 
plastic,  some  form  of  enterorrhaphy  or  intestinal  exclusion.  I,  per- 
sonally, have  rarely  seen  a  simple  plastic  successful  in  this  treatment, 
hence  mention  it  only  to  condemn  it.  There  may  be  isolated  instances, 
and  no  doubt  are,  in  which  one  of  the  forms  of  exclusion  is  indicated  in 
cases  where  a  direct  repair  would  be  too  hazardous ;  however,  its  use- 
fulness is  decidedly  limited.  The  needs  of  the  ordinary  case  are  no 
doubt  best  met  by  enterorrhaphy.  It  is  always  best  after  a  thorough 
purgation  and  cleansing  of  the  fistula  to  loosen  the  bowel  completely 
from  the  abdominal  wall,  and  to  suture  it  in  such  a  manner  as  to 
leave  the  widest  possible  lumen.  If  the  intestine  has  not  been  dam- 
aged too  much,  the  transverse  reunion  of  a  longitudinal  defect  may 
answer  all  the  requirements  of  the  case. 

An  admirable  procedure  in  many  instances,  is  a  partial,  wedge-like 
resection  which  goes  back  into  perfectly  healthy  bowel,  leaving  the 
vicinity  of  the  mysentery  intact,  and  uniting  the  cut  edges  in  a  trans- 
verse direction.  This  is  the  method  which  I  have  chosen  where  pos- 
sible, and  when  the  intestine  has  not  been  found  completely  severed ; 
it  has  given  uniformly  good  results.  In  a  small  number  of  cases,  end- 
to-end  or  less  frequently,  lateral  anastomosis  will  be  indicated  after 
partially  closed  and  widely  divided  ends  have  been  isolated  and 
brought  into  approximation. 

Multiple  fistulas  are  sometimes  extremely  difficult  to  locate,  so  far  as 
their  origin  is  concerned,  hence  exclusion  of  a  bowel  segment  may, 
for  this  reason,  or  on  account  of  a  patient's  condition,  seem  advisable. 
It  may  be  stated,  in  passing,  that  partial  exclusion  produced  by  lat- 
eral anastomosis  is  rarely  a  satisfactory  operation,  because  the  intes- 
tinal current  tends  to  follow  the  normal  direction,  past  the  anasto- 
motic opening.  A  complete  exclusion,  on  the  other  hand,  will,  as  a 
matter  of  course,  absolutely  divert  the  fecal  stream,  but  it  must  be 
undertaken  with  the  full  knowledge  that  the  fistula  must  persist  for 


194  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

the  discharge  of  intestinal  secretions,  else  the  completely  excluded 
segment  will  distend  to  a  condition  necessitating  its  removal,  or  at 
least,  permanent  drainage  of  it. 

No  fistula  can  be  closed  so  long  as  obstruction  lower  down  persists, 
hence  this  underlying  condition  must  be  treated  before  there  is  any 
thought  of  curing  the  fistula.  The  reader  is  referred  for  details  to 
the  chapter  covering  this  subject. 

Other  Varieties  of  Postoperative  Fistulse. — Parotid  fistulas,  while 
not  very  common,  are  sometimes  extremely  stubborn  and  must  be  con- 
sidered, as  they  now  and  then  complicate  operations  done  in  this  re- 
gion. An  ingenious  proposal  for  treating  them  is  that  which  is  given 
by  Le  Riche,  (Le  Riche,  R. :  Treatment  of  Permanent  Fistulas  of  the 
Parotid  by  Destroying  the  Innervation  of  the  Salivary  Gland,  Zen- 
tralbe.  f.  Chir.,  1914,  xli,  754)  and  which  is  as  follows:  "In  order 
to  avoid  total  extirpation  of  the  gland  in  stubborn  fistulas  of  the  par- 
otid, the  fistula  can  be  obliterated  by  destroying  the  secretory  nerve  of 
the  gland.  This  is  continued  in  the  auriculo-temporal  nerve,  which 
divides  into  several  branches  back  of  the  condyloid  process.  The 
nerve  is  laid  bare  at  'the  point  of  election,'  dissected  with  its  branches 
up  to  the  gland,  and  slowly  twisted  out  by  Thiersch's  method.  This 
method  has  been  used  in  three  cases  with  complete  success." 

Fistula'  of  tin  thoracic  duct  occur  only  after  accidental  wounding 
of  this  structure  during  the  removal  of  the  deep  cervical  lymphatic 
nodes  low  down  in  the  left  side.  Such  have  been  reported  by  Lund3 
and  also  by  Harvey  dishing.4  The  prevailing  symptoms  in  all  have 
been  a  more  or  less  copious  discharge  of  lymph  from  the  wound,  with 
rapid  emaciation  of  the  patient.  The  prognosis  is  not  so  bad  as  might 
be  thought  at  first,  on  account  of  the  fact  that  these  ducts  are  multiple, 
and  as  a  rule,  are  not  all  severed.  The  treatment  has  been  by  repair 
and  ligature  where  the  accident  has  been  discovered  during  the  origi- 
nal operation,  and  by  tampon,  with  subsequent  cicatrization.  In  ad- 
dition to  drainage  and  protection  of  the  skin,  one  must  naturally  do 
all  that  is  possible  to  keep  up  the  patient's  strength  until  the 
branches  of  the  duet  which  have  not  been  injured  compensate  for 
those  that  have  been  lost.  To  this  end,  the  rectal  administration  of 
5  per  cent  glucose  is  heartily  recommended. 

Bronchial  fistulie  are  not  uncommon  after  operation  for  chronic 
inflammatory  lesions  wuthin  the  chest  cavity.  Dr.  Walton  Martin5 
reported  five  cases  of  this  kind.  He  states  that  simple  straight  fistula? 
of  this  variety  have  closed  spontaneously.  If,  however,  a  portion  of 
the  fistula  constitutes  a  bulbous  enlargement  in  the  lung  tissue,  there 
is  very  little  chance  of  this  happy  outcome,  because  drainage  is  faulty. 


FISTULA  195 

The  best  treatment  seems  to  be  improved  drainage  for  a  prolonged 
period ;  in  the  event  of  this  failing,  some  form  of  plastic  operation  is 
indicated. 

Umbilical  fistula  is  fairly  common  when  the  embryonic  possibilities 
of  the  digestive  or  urinary  tracts  are  considered,  but  as  a  postop- 
erative condition,  it  must  be  rare,  only  one  instance  of  this  kind  hav- 
ing presented  itself  for  our  observation.  The  patient  was  a  small 
boy,  who  discharged  only  a  small  quantity  of  pus  from  the  navel. 
The  only  etiologic  factor  of  importance  which  could  be  elicited  was 
an  operation  for  inguinal  hernia  done  several  years  previous.  As  he 
had  pain  in  the  affected  groin  when  the  fistula  was  not  discharging, 
I  made  an  inguinal  incision  and  found  a  heavy  silk  suture  lying  in 
a  wallecl-off  cavity  just  outside  the  peritoneum,  the  same  being  con- 
nected with  the  umbilicus  by  a  tract  which  easily  admitted  a  probe 
throughout  its  entire  length.  The  removal  of  the  silk  promptly  cured 
the  patient. 

Gall  Bladder  Fistulce. — A  gall  bladder  fistula  of  temporary  na- 
ture is  so  commonly  employed  in  the  treatment  of  inflamed  conditions 
of  this  viscus,  as  to  merit  more  than  passing  mention.  It  may  per- 
sist if  the  cystic  or  common  ducts  are  obstructed,  when  it  becomes 
an  annoying,  though  not  usually,  a  dangerous  matter.  I  have  very 
frequently  explored  a  gall  bladder  under  circumstances  which  made 
cholecystectomy  seem  dangerous,  and  found  no  bile  in  the  bladder, 
nor  did  any  appear  until  some  weeks  later.  This  is  a  matter  of  ut- 
most import,  since  bile  drainage  indicates  patency  of  the  cystic  duct, 
and  if  there  is  no  obstruction  to  the  common  duct,  such  a  fistula  closes 
spontaneously.  "Where  bile  does  not  appear  after  permanent  closure 
of  the  cystic  duct  has  taken  place  and  the  need  for  gall  bladder  se- 
cretion to  escape  entails  a  mucous  fistula  of  permanent  or  intermit- 
tent character,  there  seems  to  be  no  adequate  treatment  for  this  con- 
dition except  the  secondary  removal  of  such  a  diseased  gall  bladder. 

Obstruction  of  the  common  duct  as  the  cause  of  a  gall  bladder  fis- 
tula entails  quite  another  problem ;  viz.,  the  relief  of  the  obstruction 
per  se — by  the  removal  of  the  stone.  In  many  such  instances  the  re- 
moval of  the  gall  bladder  will  be  undertaken  at  the  same  time,  pro- 
vided the  ducts  are  known  to  be  clear,  since  the  greatly  diseased 
bladder  which  usually  accompanies  this  condition,  is  of  no  value 
to  the  patient.  In  one  such  instance,  however,  I  saw  a  patient, 
after  draining  many  weeks,  pass  her  common  duct  stone  and  make 
a  spontaneous  and  permanent  recovery. 

AVhere  a  gall  bladder  fistula  appears  as  a  result  of  inflammatory 
thickening  in  the  head  of  the  pancreas,  spontaneous  cure  is  the  rule, 


196  AFTER-TREATMEXT   OF    SURGICAL   PATIENTS 

or  pancreatitis  is  treated  and  the  fistula  taken  care  of  at  the  same 
time  by  the  establishment  of  artificial  anastomosis  between  the  gall 
bladder  and  some  portion  of  the  digestive  tract.  In  cancer  of  the 
pancreas,  the  patient's  condition  would  rarely  warrant  an  operative 
procedure  calculated  to  cure  a  fistula,  which  will,  at  best,  annoy  the 
patient  for  a  limited  period  only. 

Fistula  of  the  Urinary  Tract. — Renal  fistula?  are  not  uncommon 
after  the  drainage  of  a  pus  collection  within  the  kidney,  especially 
where  there  is  urinary  obstruction  due  to  stone  I  have  done  a  ne- 
phrectomy in  a  number  of  such  instances,  because,  as  a  rule,  one  finds 
that  prolonged  suppuration  has  so  damaged  kidney  substances  as  to 
make  any  conservative  procedure  of  doubtful  value.  I  have  never 
seen  a  permanent  fistula  of  the  ureter  follow  the  removal  of  a  stone 
from  this  tube,  although  there  has  never  been  any  attempt  made  to 
suture  its  walls.  On  one  occasion,  we  were  forced  to  do  a  secondary 
nephrectomy  for  continued  profuse  urinary  drainage,  due  to  the 
complete  division  of  a  ureter,  during  an  attempt  to  relieve  a  stricture 
low  down.  Perhaps  the  im^t  common  cause  of  such  fistula?  is  that 
brought  out  by  Furniss,6  and  is  here  given:  The  author  believes  that 
the  greatest  number  of  ligated  and  severed  ureters  occur  in  hyster- 
ectomies for  uterine  fibroids.  Since  extensive  operation  for  cancer 
has  come  into  general  practice,  there  has  been  an  increase  in  the 
number  of  ureterovaginal  fistula-.  In  this  operation  the  injury  is 
most  often  due  to  temporary  clamping  of  the  ureter,  which  is  later 
followed  by  necrosis  and  sloughing.  Sampson  has  stated  that  pro- 
longed tying  of  the  ureter  is  less  dangerous  than  temporary  clamp- 
ing, and  this  statement  has  been  proved  by  clinical  observations. 

He  writes:  "Most  fistulae  result  from  necrosis  of  the  ureter,  due 
to  rough  handling,  too  extensive  dissection  or  clamping.  In  all  these 
list  like  there  is  a  marked  inflammatory  condition  around  the  end  of 
the  ureter,  and  this  is  to  be  remembered  in  operating.  In  the  begin- 
ning it  is  so  great  that  the  repair  of  the  abdominal  fistula?  by  another 
anastomosis  has  little  chance  of  success.  In  the  incomplete  variety, 
especially  when  only  a  small  spot  on  the  ureteral  wall  has  been  in- 
jured, there  is  not  so  great  a  likelihood  of  the  ureter  becoming  ob- 
structed, and  for  this  reason,  the  function  of  the  kidney  is  not  im- 
paired. After  the  lapse  of  four  months,  with  no  improvement,  there 
is  little  hope  of  the  fistula  closing." 

Fistula  of  the  Urinary  Jilml*!,  ,•  are  most  commonly  of  the  vesico- 
vaginal type,  since  this  vis, -in  i^  so  often  exposed  to  injury  in  gyne- 
cologic and  obstetric  practice.  The  diagnosis  and  general  circum- 
stances surrounding  such  cases  are  too  well  known  to  make  extended 


FISTULA  197 

mention  needed  here.  "Ward7  lias  advanced  a  plan  for  treating  these 
cases,  which  should  be  read  in  the  original  to  be  appreciated. 

Parham8  reports  two  unsuccessful  attempts  to  close  such  a  fistula, 
followed  by  a  third  successful  issue  after  the  Ward  technic  was  em- 
ployed. Multiple  operations  have  been  the  rule  rather  than  the  ex- 
ception, where  an  attempt  has  been  made  to  close  a  vesicovaginal  fis- 
tula. The  location  of  such  a  lesion  and  the  amount  of  scar  tissue 
around  it  may  prove  to  be  determining  factors  in  the  treatment.  An 
excision  of  the  tract  with  multiple  layer  suture  on  as  broad  surface 
as  can  be  secured,  has  been  attended  with  ultimate  success  in  all  of 
our  cases,  although  I  have,  perhaps,  been  fortunate  in  encountering 
fistulas  of  only  moderate  size,  which  could  be  fairly  easily  mobilized. 
I  have  invariably  employed  a  permanent  catheter,  and  haAre  felt  that 
I  was  aided  by  keeping  the  patient  from  turning  on  the  back  at  any 
time  during  the  week  following  the  operation,  thus  minimizing  the 
tendency  of  gravity  to  defeat  my  aim.  An  interesting  vesicoutero- 
vaginal fistula  was  treated  by  MacLean9  and  reported.  His  method 
was  to  swing  the  cervix  into  the  bladder  and  anchor  it  there. 

Fistulas  connecting  the  bladder  with  some  portion  of  the  colon  have 
occurred  frequently  only  after  operations  for  inflammatory  diseases 
of  the  pelvic  viscera  in  women.  Duncan10  reports  one  such  in  which 
the  condition  was  successfully  treated  by  a  relaparotomy,  with  sep- 
arate closure  of  bladder  and  rectum. 

Cunningham11  describes  the  treatment  of  enter ovesical  fistulas  from 
the  viewpoint  of  the  urologist.  He  divides  the  operative  treatment 
into  (1)  abdominal  section,  with  separate  suture  of  both  viscera,  (2) 
perineal  operation  for  a  very  low  lesion,  with  permanent  catheter  and 
packing  of  rectal  wound;  (3)  colotomy  for  the  purpose  of  draining 
the  feces;  (4)  suprapubic  cystotomy  where  nothing  else  can  be  done 
to  rid  the  sufferer  of  the  presence  of  the  feces  in  the  bladder. 

No  doubt  the  most  common  form  of  enterovesical  fistula  which 
affects  the  male,  is  that  between  bladder  and  rectum,  and  which  com- 
plicates perineal  prostatectomy.  Now  that  most  surgeons  employ  the 
suprapubic  method  so  extensively,  this  complication  is  less  seen  than 
formerly.  My  own  experience  in  this  line  is  very  small,  but  I  must 
admit  with  chagrin,  that  I  can  not  claim  a  single  success  in  its  opera- 
tive treatment,  hence  urge  prophylaxis  above  every  other  considera- 
tion. Young  and  Stone12  have  treated  urethrarectal  fistulas  in  several 
instances,  by  a  plan  which  might  be  modified,  it  seems  to  me.  and 
adapted  to  the  treatment  of  vesicorectal  conditions  of  similar  na- 
ture. They  divide  their  operation  into  four  essential  steps.  These 
are: 


198  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

(1)  Suprapubic  drainage. 

(2)  Kesection  of  a  cuff  of  rectal  mucosa  con- 
taining the  fistula. 

(3)  Suture  of  the  urethral  orifice. 

(4.)  Building  up  of  a  heavy  perineal  body 
with  repair  of  the  sphincter  ani. 
Urethral  fistulse  occur  according  to  Lothrope13  after  extravasation, 
perineal  prostatectomy  and  operations  for  stricture. 

Operative  treatment  should  be  deferred,  according  to  this  author, 
until  the  acute  inflammatory  reaction  has  passed,  then  the  fistula 
should  be  isolated  and  dissected  loose  with  a  sound  in  the  urethra, 
after  which  it  is  ligated  near  its  inner  end  and  the  divided  tissues 
united  in  layers  over  the  sound. 

BibliogTaphy 

lYomig,  Hugh  II.:     Personal  communication. 

2Hilgenreiner :     Die  Geschwure  und   die  erworbenen    Fisteln,  Des  magen  Darm- 

kanals,  Stuttgart,  Verlag,  von    Ferdinand    Enke. 
sLund:     Boston  Med.  and  Surg.  Jour.,  is!*1.),  exl,  354. 
*Cushing,  Harvey:     Ann.  Surg.,  1898. 
sMartin,  Walter:      Med.  Rec,  New  York,  Nov.  14,  1914. 
sFurniss,  H.  D.:     Some  Observations  upon  Post-operative  Ureteral  Fistula'.  Am. 

Jour.  Obst.,  1915,  p.  837. 
rWard:     Surg.,  Gynec.   and  Obst.,   1910,  xi,  22. 
BParham:     Surg.,  Gynec.  and  Obst.,   1913,  xvii,  368. 
9MacLean:     Jour.  Gynec.  and  Obst.,  British  Empire,  1913,  xxiv,  274. 
"Duncan:      Am.  Jour.  Obst.,    1913,   Iwii,  148. 
"Cunningham:     Surg.,  Gynec.  and  Obst.,  1915,  xxi,  510. 
i2Young  and  Stone:     Tr.  Am.  Assn.  Genito-Urinary  Surgeons,  1913,  vii,  270. 
isLothrope:     Boston  Med.  and  Surg.  Jour.,  clxviii,  188. 
Also  consulted  the  following: 
Beer:      Ann.  Surg.,  1915,  l.xii,  576. 
Bryan:      Ann.  Surg.,  1916,  lxiii. 

Crookall:     Internat.  Jour.  Surg.,  February,  1913,  ]>.  54. 
Cunningham,  Jr.:     Recto  vesical  and  Enterovesical  Fistulae,  Boston,  Tr.  Am.  Urol. 

Assn.,   1915,  p.  433. 
Deaver:     Therap.  Gaz.,  March  15,  1913,  p.  153. 
Drueck:      Med.  Rec.,  New  York,  January  3,  191  I.  p.  L5. 
Elting:      Ann.  Surg.,  1912,  lvi,  71  I. 

Emmet:     Vesico-vaginal   Fistula,  New  York,  "Wm.   Wood  £   Co.,    1868. 
Freeman:     Suppurating  Abscess,  sinus  ami   Fistula,  Ulcer  and  Gangrene,  Keen's 

Surgery,  W.  B.  Saunders  Co.,  Philadelphia. 
Frey,  Emil  K.:     Beitrag  zur  Frage  der  Entstehung  und  Behandlung  der   Fistula 

Ani,  Mtinchen.  mod.  Wchnschp.,  1911.  p.  Is:,. 
Hemor  and  Clostens,  John  Arderne,  P.  T.  Kegan:      Treatises  of  Fistula   in    Aim, 
Trubner   &   Co.,   Ltd.,   London;    Henry   Frowde,   Oxford    University   Press 
New  York,  1910. 
Landsman:     Ano-rectal  Fistula,  New  YTork  Med.  Jour.,  1916,  p.  829. 
Losee:     Esophago-tracheal   Fistula,  Tr.  New  York.  Acad.  Med.,  Am.  Jour.  Obst., 

1914. 
Matthews:      Fistula  in  Am.,  st.  Louis,  Lambert  &  Co.,  1885.     (A  paper  read  be- 
fore the  Mississippi  Valley   Medical  Association  at  Indiana,  September  19, 
1883.) 
Niendorf,    Erich:     Zur    Lehre    von    dem    fisteln    naeh    Mondeville,    Berlin,    1896, 

Gedruckt  bei  L.  Schumacher. 
Pennington:     New  York  Med.  Jour.,  1915,  p.  785. 


CHAPTEE  XXIV 

SINUSES 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Sinuses  are  so  frequently  seen  after  operations  that  the  proper  care 
and  attention  of  this  complication  demands  more  than  passing  men- 
tion. In  fact  timely  aid  in  such  conditions  rarely  fails  to  bring  re- 
ward in  the  form  of  relief  of  the  causative  factors  with  the  ultimate 
cure  of  the  patient. 

A  sinus,  as  generally  understood,  is  a  tract  of  varying  length  and 
size,  passing  from  some  point  of  tissue  necrosis  or  actual  abscess  to 
the  free  mucous  or  skin  surface.  In  postoperative  cases  the  sinus 
most  usually  results  from  some  portion  of  the  wound  which  has  not 
healed;  or  where  pus  has  burrowed  in  parts  of  the  subcutaneous 
tissues  with  secondary  openings  at  the  body  surface.  Sinus  formation 
following  operations  for  osteomyelitis  is  a  common  occurrence  as  is 
also  often  the  case  after  a  pus  appendix,  though  a  tract  may  form 
after  other  abdominal,  pelvic  or  thoracic  operations.  A  foreign  body 
left  in  the  abdominal  cavity  (such  as  a  sponge,  etc.)  not  infrequently 
is  the  source  of  a  persistent  drainage  tract.  The  sinus  will  continue 
so  long  as  the  offending  material  is  present,  as  is  the  case  in  the  bony 
sequestrum  in  the  osteomyelitis,  and  the  sloughed  off  appendix  in 
the  pus  appendix  cases.  In  other  instances  the  constant  irritation 
of  bile,  saliva,  urine,  etc.,  may  be  the  cause  of  a  persistent  sinus. 

Sinuses  may  present  themselves  in  surgical  wounds  as  a  result  of 
nonabsorbable  ligature  material,  absorbable  ligatures  which  have  be- 
come infected  or  other  irritative  factors  as  a  sequela  to  the  operative 
procedure  alone.  Foreign  bodies,  such  as  dirt,  wood,  pieces  of  steel 
or  a  bullet  may  be  the  seat  of  annoying  discharging  tracts  in  wounds 
caused  by  injuries.  In  any  wound  where  there  is  improper  rest  due 
to  muscular  movements,  or  in  tissues  of  low  vitality  sinuses  may  per- 
sist as  a  result  of  these  reasons  alone.  In  patients  with  poor  general 
health  sinus  formation  is  the  rule  rather  than  the  exception.  Thus  in 
the  tuberculous  drainage  is  not  even  attempted  because  of  this  fact. 

The  lesson  never  to  drain  a  tuberculous  lesion  was  learned  long 
ago  in  the  attempts  to  handle  tuberculous  appendicitis  in  the  usual 
way,  which  so  often  resulted  in  nonhealing  of  the  wound  and  the  de- 
veloping of  a  persistent  sinus. 

}99 


200  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

The  treatment  first  consists  in  determining  the  cause  of  the  con- 
dition and  measures  undertaken  at  once  to  remove  it.  No  sinus  will 
ever  permanently  close  so  long  as  the  offending  causative  factor  is 
left  undisturbed.  For  this  reason  one  must  endeavor  to  keep  the 
external  opening  free  from  the  crusts  which  will  form  over  it,  and 
if  necessary  insert  a  rubber  drain  throughout  the  extent  of  the  tract 
and  from  time  to  time  cut  away  with  a  sharp  pointed  scissors  the 
granulations  as  they  become  obstructive.  The  same  thing  may  be 
accomplished  with  the  silver  nitrate  stick  or  a  sharp  curette.  This 
instrument  is  indeed,  very  useful  in  long  tortuous  tracts  which  tend 
to  close  by  granulation  tissue  a  considerable  distance  from  the  out- 
let. While  the  tract  itself  is  kept  open,  nature  has  a  chance  to  dis- 
charge any  offending  material  from  the  bottom  of  the  sinus  and  to 
heal  the  cavity  in  the  usual  way.  Pus  and  all  other  discharges  aris- 
ing from  granulating  walls,  having  a  free  outlet,  allows  the  walls  to 
quickly  collapse  and  soon  to  be  completely  obliterated  by  means  of 
granulation  followed  by  scar  tissue.  Such  a  process  in  the  very  large 
cavities  may  require  months  to  complete  its  work.  During  this  time 
one  must  persist  in  keeping  a  free  opening  for  the  secretions. 

If  there  is  any  reason  to  believe  that  the  sinus  persists  because  of 
some  foreign  body  which  has  not  been  discharged  despite  every  effort 
to  give  the  tract  free  drainage,  one  should  probe  the  cavity  thoroughly 
in  the  hope  of  dislodging  the  foreign  member,  or  if  it  be  a  piece  of 
gauze  or  suture,  one  should  entangle  it  in  the  instrument  and  thus 
remove  it.  A  sloughed  off  appendix,  foreign  body  left  in  the  abdom- 
inal cavity  or  wound  will  probably  require  a  secondary  operation. 
A  sequestrum  of  bone  may  also  require  such  radical  treatment, 
though  time,  without  further  measures  other  than  those  mentioned 
above,  will  usually  correct  difficulties  arising  from  this  source. 

A  sinus  may  persist  long  after  the  causative  factor  has  been  re- 
moved. Such  is  indeed  the  case  usually  in  those  instances  where  it 
is  necessary  to  keep  a  free  drainage  tract  over  unusual  periods.  The 
walls  of  the  sinus  become  infiltrated  and  hardened  due  to  the  chronic 
inflammatory  process.  Sinuses  arising  from  bone  or  cartilage  natu- 
rally persist  because  of  the  nature  of  the  tissue.  This  alone  prevents 
collapse  of  the  sinus  cavity  and  therefore  forces  the  defect  to  be 
closed  wholly  by  granulation. 

Constant  irritating  discharges  such  as  bile,  etc.,  will  often  cause  the 
sinus  to  persist.  In  such  instances  the  granulations  often  develop 
slowly  and  measures  must  be  employed  to  stimulate  not  only  the 
granulation  tissue  itself  by  scraping  the  walls  of  the  sinus  with  a 
curette  until  healthy  tissue  is  reached,  but  also  to  actually  dissect  out 


SINUSES  201 

the  entire  tract  and  close  it  with  buried  catgut  sutures.  When  the 
bottom  of  a  sinus  is  so  situated  that  an  opening  can  be  made  to  the 
outside  and  thereby  give  through  and  through  drainage,  this  should 
be  done.  Such  a  maneuver  permits  of  thorough  cleansing  with  some 
antiseptic  solution  and  frequent  irrigation  will  discourage  bacterial 
growth  and  hasten  the  growth  of  the  reparative  tissue.  Irrigations 
of  sinuses  with  4  per  cent  boric  acid  solution  or  Dakin's  fluid  three  or 
four  times  a  day  is  encouraged  in  those  instances  where  the  sinus  does 
not  extend  into  the  peritoneal  cavity. 

For  sinuses  about  the  mouth,  or  those  resulting  from  surgical 
wounds  of  the  neck  I  usually  employ  80  per  cent  alcohol  or  %  per 
cent  alcoholic  solution  of  iodine  once  a  clay.  The  same  solution  may 
be  utilized  in  any  sinus  where  the  solution  readily  returns.  One 
should  never  employ  solutions  which  will  injure  the  new  tissue  along 
the  tract  during  the  attempt  to  cleanse  it  of  discharge  and  clear  it 
of  bacteria.  For  this  reason  the  alcohol  is  permissible  but  once 
a  day,  whereas  solutions  as  mentioned  previously  may  be  used  much 
more  frequently.  When  the  cause  of  the  condition  can  be  with  cer- 
tainty eliminated,  so  far  as  foreign  bodies  are  concerned,  other  reme- 
dies in  addition  to  the  ordinary  cleansing  of  the  tract  can  be  employed 
with  success.  In  the  most  persistent  sinuses  these  become  necessary 
if  operative  interference  as  suggested  above  is  not  to  be  considered. 

Among  the  many  suggested  remedies,  iodized  phenol  as  employed 
by  Cotes1  may  be  mentioned  though  remedies  which  have  proved  of 
value  through  years  of  usage,  such  as  Beck's2  paste,  probably  should 
be  used.  His  method  was  first  employed  as  a  diagnostic  measure. 
The  paste  was  injected  into  sinuses  and  x-ray  pictures  taken  later  to 
show  the  tract  in  detail.  It  was  soon  found,  however,  that  following 
the  injection,  particularly  in  tuberculous  sinuses,  not  infrequently 
the  tract  would  heal  without  further  measures  being  necessary.  It 
was  discovered  that  the  bismuth,  being  antiseptic,  besides  forming  a 
network  for  the  granulations  to  grow  in,  offered  the  best  medium  for 
the  healing  of  these  defects.  It  also  acted  as  a  foreign  body,  thereby 
stimulating  leucocytosis  and  by  its  mechanical  action  kept  the  walls 
of  the  sinus  open.    This  permitted  closure  from  the  bottom  upwards. 

As  generally  employed,  the  sinus  is  injected  with  a  "liquid  bis- 
muth vaseline  paste,"  by  means  of  an  ordinary  glass  syringe  (usually 
20  c.c.)  every  other  clay  until  the  tract  ceases  to  discharge.  The  paste 
consists  of  bismuth  subnitrate,  1  ounce,  vaseline,  2  ounces.  The  two 
are  mixed  over  a  water-bath  and  the  mixture  injected  while  it  is  at 
a  temperature  of  110°  to  120°  F.  It  should  be  put  into  the  sinus 
under  slight  pressure  so  as  to  fill  every  part  of  the  tract.     After 


202  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

a  few  clays,  when  all  discharge  has  stopped,  Beck2  uses  a  mixture 
which  forms  a  much  harder  paste  at  body  temperature.  This  forms 
a  more  substantial  framework,  inside  the  sinus  tract,  for  the  granu- 
lation tissue  to  fill.  To  the  3  ounce  mixture  of  bismuth  and  vaseline, 
Beck  adds  75  grains  each  of  white  wax  and  soft  paraffin.  Beck2 
states  that  the  tract  closes  after  the  employment  of  the  latter  paste, 
and  in  most  instances  remains  closed,  during  which  time  the  paste  be- 
comes absorbed  and  replaced  by  granulation  tissue. 

Soon  after  the  use  of  Beck  paste  in  the  ordinary  sinuses  which 
occur  in  the  body,  other  than  those  connected  with  the  thorax, 
Ochsner3  demonstrated  its  value  in  this  capacity,  stating  that  sinuses 
resulting  from  operations  in  empyema  cases  soon  become  sterile  and 
rapidly  close  after  injecting  the  mixture  in  the  usual  way. 

Like  all  good  remedies  applicable  in  medicine,  the  paste  was  found 
not  to  be  useful  in  every  case  of  chronic  sinus,  tuberculous  or  other- 
wise. 

Among  the  other  pastes  are  Mitchell's,4  which  consists  of  a  mix- 
ture of  equal  parts  of  petrolatum  and  chalk.  He  states  that  this 
paste  -will  accomplish  the  same  result  as  the  bismuth  paste  and  that 
it  is  even  more  useful,  since  it  contains  calcium  which  is  an  active 
chemical  and  that  poisoning  is  not  possible  with  chalk  paste. 

Blanehard5  simply  employs  white  wax  one  part  to  eight  parts  of 
vaseline.  In  cases  where  an  antiseptic  paste  is  desirable  as  in  viru- 
lent infections,  he  adds  iodine  crystals  which  have  been  reduced  to  a 
powder  by  rubbing  in  a  mortar  to  which  20  per  cent  potassium  iodine 
solution  has  been  added.  Two  or  three  grains  of  the  powder  are 
mixed  with  the  paste  and  injected  into  the  sinus,  using  the  same  tech- 
nic  as  with  bismuth  paste.  If  x-rays  are  to  be  taken  of  the  sinus, 
Blanehard  uses  a  mixture  of  f err i-sub carbonate  one  part  to  two  parts 
of  white  vaseline.  The  mixture  is  boiled  and  at  the  same  time  it  is 
thoroughly  mixed.  The  author  claims  to  have  cured  ultimately  65 
per  cent  of  old  tuberculous  sinuses  which  is  as  many  as  those  cured 
by  the  bismuth;  the  attendant  bad  effects  of  the  latter  drug  such  as 
clogging  of  dependent  portions  of  the  abscesses  or  sinus  walls  with 
the  heavy  metal  or  poisoning  are  entirely  eliminated. 

SweekG  does  not  use  injections  of  any  kind,  since  he  feels  that  any 
method  as  outlined  above  in  killing  off  the  bacteria  we  destroy  the 
newdy  formed  granulation  tissne.  He,  therefore,  uses  a  germicidal  gas 
which  he  causes  to  pass  into  the  sinus  from  ten  to  twenty  minutes 
each  day  or  every  other  day.  depending  on  the  severity  of  the  case. 
Air  is  passed  through  crude  spirits  of  resin  and  then  through  the 
poles  of  an  electric  arc,  from  here  into  a  tin  gallon  jar  from  which 


SINUSES  203 

it  passes  into  the  sinus.  The  slight  aging  the  gas  undergoes  in  pass- 
ing into  the  jar  causes  it  to  have  a  somewhat  irritating  effect  on  the 
nose  and  bronchi,  but  does  not  irritate  the  wound  to  a  noticeable 
degree. 

Sweek3  claims  that  the  minute  or  minute  and  one-half  which  the 
gas  requires  in  passing  through  the  jar  so  ages  it  that  its  bactericidal 
power  is  materially  enhanced.  He  claims  that  the  wound  healing 
is  not  retarded  in  any  degree  and  that  we  can  expect  greater  results 
from  this  gas  than  any  known  germicide.  His  method  should  be 
tried  before  one  despairs  in  the  treatment  of  this  annoying  complica- 
tion. 

Bibliography 

iCotes:     Brit.  Med.  Jour.,  1911,  ii,  15-92. 
sBeck:     Jour.  Am.  Med.  Assn.,  1908,  1,  868. 
sOchsner:     Jour.  Am.  Med.  Assn.,  1909,  liii,  319. 
^Mitchell:     Jour.  Am.  Med.  Assn.,  1911,  lvii,  394. 
sBlanchard:     Med.  Rec,  New  York,  1912,  lxxxi,  941. 
eSweek:     Interstate  Med.  Jour.,  1916,  xxiii,  225. 


CHAPTER  XXV 

DRUG  ADDICTION  IN  SURGICAL  PATIENTS 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

It  is  common  experience  that  the  average  surgeon  pays  very  little 
attention  to  drug  addiction,  if  discovered  at  all,  in  his  patients,  and 
inclines  to  regard  it  as  a  matter  which  does  not  concern  him.  This 
stand  can  he  defended  if  the  surgeon  accepts  the  responsibility  for 
his  work  during  the  operation  only,  but  anything  which  has  to  do 
with  the  recovery  and  subsequent  well  being  of  his  patient  should 
command  just  the  same  interest  and  respect. 

Bishop1  holds  that  the  medical  profession  has  regarded  the  con- 
tinued use  of  a  narcotic  drug  as  the  element  of  paramount  importance 
in  drug  addiction  and  that  too  little  attention  has  been  given  to  the 
action  of  the  drug,  which  produces  such  a  condition,  and  that  the 
"physical  mechanism''  of  drug  addiction  has  greater  influence  in  the 
healing  and  repair  than  had  been  formerly  supposed. 

He  points  out  that  very  many  surgical  eases  have  terminated  badly 
or  at  least  unsatisfactorily,  solely  because  the  surgeon  failed  to  grasp 
the  importance  of  the  drug  addiction,  and  his  inability  to  success- 
fully deal  with  such  a  condition  existing  intercurrently  in  surgical 
patients.  The  medical  treatment  of  narcotic  drug  addiction  has  con- 
cerned itself  chiefly  in  withdrawing  the  drug.  Until  this  has  been 
accomplished,  operators  will  frequently  not  attempt  any  work  on  a 
patient,  since  Mich  have  been  considered  poor  operative  risks,  besides 
being  difficult  to  handle.  But  such  a  stand  is  not  justified  by 
clinical  facts.  "The  habitue  is  not  a  poor  surgical  risk  merely  because 
he  is  addicted  to  his  drug."  The  slowness  of  recovery  and  lack  of  re- 
pair which  have  been  noted  in  these  cases  is  not  due  to  the  drug  of 
which  he  is  the  slave,  but  rather  to  the  fact  that  his  surgeon  is  unable 
to  cope  with  his  acquired  condition,  or  in  many  instances,  it  is  not 
even  recognized.  There  can  be  no  doubt  that  such  patients  have 
been  operated  upon  and  have  passed  through  a  satisfactory  recovery 
and  convalescence  without  their  addiction   even  being  suspected. 

Provision  is  usually  made  by  the  wiser  "addict"  for  such  emergen- 
cies and  he  himself,  controls  his  disease.  For  it  is  a  disease2  and  "the 
amount  of  the  drug  which  the  patient  must  use  is  of  minor  importance 
compared  with  his  functional,  nutritional  and  metabolic  efficiency." 

204 


DRUG   ADDICTION    IN    SURGICAL   PATIENTS  205 

According  to  Bishop,  the  satisfactory  recovery  of  a  narcotic  addict 
from  a  surgical  condition  depends  largely  upon  his  "functional  bal- 
ance ' '  and  upon  his  ' '  organic  adequacy. ' '  Such  are  largely  under  the 
control  of,  and  vary  with,  the  extent  to  which  the  patient  is  kept  in 
"narcotic  drug  balance."  It  follows,  then,  that  the  reduction  of  the 
dose  of  the  accustomed  drug  below  the  amount  which  the  addict  phy- 
sically needs  is  not  only  without  justification,  but  also  is  harmful  to 
the  patient  and  the  result  is  seriously  prejudiced. 

Why  such  a  condition  should  present  itself  at  all  as  a  menace  to 
surgical  procedure  has  never  been  explained.  Drug  habits  have  been 
common  since  time  immemorial.  The  use  of  opium  has  been  practiced 
by  the  Orientals  throughout  the  ages.  These  people  used  it  in  the  be- 
lief that  the  drug  was  helpful  to  them,  and  even  today,  they  are  still 
using  it  in  much  the  same  way  as  the  Western  peoples  use  coffee, 
tea,  or  tobacco. 

Its  use  is  mentioned  in  the  Egyptian  hieroglyphics,  and  centuries 
later  in  the  writings  of  Homer.  Since  the  beginning  of  the  nine- 
teenth century,  however,  chemical  study  and  experimentation  have 
revealed  its  composition,  and  since  that  time,  the  alkaloids  of  opium 
have  played  a  more  or  less  prominent  part.  The  danger  of  morphin- 
ism was  first  recognized  in  1866,  in  France,3  the  hypodermic  use  of 
this  drug  having  at  that  time  come  into  prominence  there. 

In  this  country,  opium  as  such,  is  not  commonly  used.  Morphine 
is  the  alkaloid  of  choice.  It  is  said  that  85  per  cent  of  habitues  take 
it  subcutaneously.  Occasionally,  codeine  or  heroin  is  used  instead. 
Opium  is  usually  smoked,  though  it  is  taken  by  mouth  in  the  form 
of  opium  pills  or  laudanum.  Cocaine  may  also  be  used  by  such 
addicts,  the  drug  being  taken  by  insufflation  or  by  mouth. 

Morphine  addicts,  like  chronic  alcoholics,  are  divided  into  two 
great  classes;  those  who  are  habitual  users  and  those  who  use  the 
drug  periodically ;  the  morphine  or  opium  being  entirely  abandoned  in 
the  interval.4 

It  is  common  to  find  among  women4  periodic  addicts  to  this  drug, 
traceable  in  most  cases,  to  some  pelvic  trouble,  to  recurring  attacks  of 
headache  or  to  neuralgia.  The  habitual  user  is  much  more  easily  han- 
dled than  is  the  periodic  addict.  However,  the  former  class  is  more 
difficult  to  treat  than  the  class  of  patients  who  have  taken  large 
amounts  of  morphine  but  for  only  a  short  period  of  time. 

The  symptoms  of  morphinism  can  not  be  fully  gone  into  here,  but 
as  seen  in  the  chronic  form,  there  is  a  change  of  personality  indicated 
by  alternation  of  mood ;  viz.,  periods  of  depression,  suddenly  followed 
by  intervals  of  euphoria.     To  this  is  usually  added  a  capricious  ap- 


206  AFTER-TREATMENT   OF    SURGICAL    PATIENTS 

petite,  constipation  or  possibly  diarrhea.  The  nutrition  suffers,  the 
subcutaneous  tissue  gradually  shrinks  and  the  skin  becomes  loose. 
The  face  is  usually  ashen  or  sometimes  deep  red  in  color.  The  pupils 
are  generally  contracted  and  react  poorly  to  light.  There  may  occur 
double  vision.  Hoarseness,  thirst,  and  tremor  are  common  symptoms. 
If  the  patient  has  been  deprived  of  his  drug  for  any  length  of  time,  he 
becomes  restless,  anxious,  and  salivation  with  coryza  probably  appear; 
he  may  become  nauseated,  and  vomit.  Disturbances  of  vision,  neural- 
gic pains  and  a  choreic  form  of  jactitation  make  their  appearance. 
The  pupils  become  dilated,  a  stage  of  wild  excitement  develops,  and,  no 
matter  how  secretive  the  man  may  have  been  before,  he  now  begs  for 
his  drug. 

The  action  of  narcotic  drug-  upon  the  organism  reveals  itself 
through  inhibition  of  body  function.  Glandular  activity  is  arrested 
and  the  metabolic  processes  are  markedly  diminished.  The  smooth 
musculature  throughout  the  body  is  paralyzed  by  their  action,  and 
since  this  class  constitutes  the  musculature  of  the  intestinal  tract, 
peristalsis  is  inhibited.  This  results  in  diminution  of  the  intestinal 
glandular  secretion  and  therefore  elimination  suffers.  This  inhibi- 
tion of  function  not  alone  causes  a  storage  of  poisonous  drug  within 
the  body,  but  prevents  the  complete  elimination  of  toxic  products 
which  are  the  result  of  tissue  destruction,  and  interferes  with  me- 
tabolism as  well. 

Such  a  condition.  Bishop  says,  brines  aboul  autointoxication.  He 
also  points  oul  that  "the  predominating  manifestations  of  this  disease 
depend  upon  the  extent  of  the  inhibition  of  function  and  upon  the 

degr >f  autointoxication."    The  circulatory,  digestive  and  nervous 

systems  are  affected  by  such  a  condition.  The  mental  deterioration 
and  other  symptoms  so  often  ascribed  to  the  '\v\\<j:  alone  are  as  a 
matter  of  fact,  the  result  of  these  factors. 

A-  to  the  treatment,  one  must  study  the  individual  case.  The  drug 
should  be  supplied  in  such  amounts  as  are  necessary  to  carry  on  the 
body  functions.  The  inhibitory  effect  should  be  cut  to  the  minimum 
by  giving  it  a1  sufficiently  wide  intervals.  This  inhibition  of  function 
can  be  lessened  by  relieving  the  patient,  so  far  as  possible,  of  fear, 
worry,  anxiety  or  criticism,  and  by  trying  to  gain  his  confidence  and 
respect.  The  physician  must  not  consider  the  condition  anything  else 
than  a  disease,  since  the  patient  takes  the  drug  to  meet  the  definite 
indications.  The  mere  fact  that  a  patient  indulges  does  not  constitute 
his  disease  or  the  withdrawal  of  this  drug  constitute  his  cure.  The 
dose  must  not  be  reduced  until  the  physical  need  for  this  substance 
has  been  diminished.     Unskilled  withdrawal   is  responsible  for  many 


DRUG   ADDICTION   IN   SURGICAL   PATIENTS  207 

relapses.5  "An  improved  tone  of  the  body,  an  increased  ability  to 
assimilate  food  taken,  and  a  proper  elimination  are  of  far  more  im- 
portance than  the  mere  fact  that  a  smaller  amount  of  the  drug  is 
being  taken."  When  the  patient  has  progressed  far  enough  in  the 
convalescence  to  permit  of  active  eliminative  processes  being  carried 
out,  the  autotoxemia  can  be  disposed  of.  As  suggested  by  Pettey,6 
one  must  first  overcome  the  inhibitive  effects  of  the  drug  in  order  to 
get  the  best  eliminative  results  in  his  efforts  to  eradicate  the  products 
of  autointoxication.  Pettey  uses  strychnine  in  sufficient  doses  to  stim- 
ulate the  semiparalyzed  intestines  to  efficient  peristalsis.  Efficient 
peristalsis  being  maintained  and  elimination  being  active,  Pettey 
found  that  only  one-fourth  of  the  usual  quantity  of  drug  was  neces- 
sary to  meet  all  the  patient's  demands,  and  after  a  few  days,  the 
opiate  can  be  withdrawn  entirely.  Nausea,  colic,  and  other  gastro- 
intestinal symptoms  which  are  so  often  noted  following  other  forms 
of  treatment  fail  to  appear,  and,  within  a  few  more  days,  the  pa- 
tient can  be  discharged  without  collapse  ever  having  threatened. 

Another  method  of  treatment  may  be  employed,  even  in  weak  or 
debilitated  persons,  who  have  been  prepared  along  the  lines  suggested 
above.  Since  this  method  takes  but  a  short  time,  it  is  desirable,  if 
possible,  to  have  the  patient  well  advanced  in  the  convalescence  be- 
fore any  attempt  is  made  to  relieve  the  drug  addiction  permanently. 
As  suggested  by  Town7  and  later  supported  by  Lambert,8  it  is  as 
follows,  according  to  Hare :  ' '  The  patient,  being  under  absolute  con- 
trol as  to  his  ability  to  obtain  morphine,  is  given  five  compound 
cathartic  pills  and  in  addition,  five  grains  of  blue  mass.  Six  hours 
later,  if  these  have  not  acted,  a  saline  purge  is  given.  After  the  pa- 
tient has  three  or  four  copious  movements,  he  receives,  by  mouth  or 
hypodermic  injection,  according  to  his  custom  of  taking  the  drug, 
two-thirds  to  three-fourths  of  his  total  daily  intake  in  three  divided 
doses  at  half -hour  intervals.  Six  drops  of  a  mixture  of  tincture  of 
belladonna,  2  parts;  fluid  extract  of  xanthoxylin,  1  part;  and  fluid 
extract  of  hyoscyamus,  1  part,  are  given  in  a  capsule  at  the  same  time 
as  the  morphine,  cocaine  or  alcohol  and  repeated  every  hour  for  six 
hours.  At  the  end  of  six  hours,  the  dose  of  this  mixture  is  increased 
by  two  drops  and  it  is  continued  every  subsequent  hour,  day  and 
night,  being  increased  by  2  drops  every  6  hours  until  16  drops  are 
given  at  a  dose.  If  the  patient  shows  very  marked  symptoms  of  the 
physiologic  action  of  the  belladonna  mixture,  the  amount  may  be  de- 
creased, but  on  the  other  hand,  if  he  is  resistant  to  the  drug,  it  must 
be  increased  up  to  20  drops  every  hour.  Ten  hours  after  the  first  dose 
of  morphine  has  been  received,  the  patient  is  again  given  five  com- 


208  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

pound  cathartic  pills  and  five  grains  of  blue  mass ;  if  the  bowels  do 
not  act  in  6  or  S  hours,  a  vigorous  saline  purge  is  administered.  The 
morphine  is  used  after  this  purgation  in  half  the  original  dose,  and 
ten  hours  later  the  same  number  of  compound  cathartic  pills  and  the 
same  amount  of  blue  mass  is  given.  After  thirty-six  hours  have 
elapsed  from  the  beginning  of  the  treatment,  the  third  dose  of  mor- 
phine, which  is  one-fourth  of  the  original  amount  is  given,  and  it  is 
claimed  that  this  is  usually  the  last  which  is  needed.  Forty-six  hours 
after  the  beginning  of  the  treatment,  the  compound  cathartic  pills  and 
blue  mass  are  given  again,  followed  by  a  saline,  and  possibly  as  late 
as  the  fifty-sixth  hour  of  treatment,  a  fourth  small  dose  of  morphine 
may  be  used  with  two  ounces  of  castor  oil."  If  the  treatment  nau- 
seates the  patient,  calomel  in  small  doses  combined  with  a  little  so- 
dium bicarbonate  may  be  used  instead  of  the  pills.  The  pain  which 
such  a  treatment  will  cause,  may  be  eased  with  codeine  or  dionine. 
Strychnine  and,  if  necessary,  digitalis  should  be  used  as  supportive 
measures.  Osier  says  the  most  valuable  tonics,  following  the  treat- 
ment, are  those  which  contain  some  form  of  phosphorus  and  arsenic. 

Other  forms  of  treatment  have  been  devised  by  Erlenmeyer,9  Sce- 
leth,  and  others.10  Regardless  of  the  method,  however,  the  future 
of  such  a  patient  musl  be  guarded.  Placed  in  good  environments, 
given  proper  diet  and  plenty  of  exercise,  he  will  gain  soon  in  weight 
and  in  spirits  while  his  health  will  become  excellent.  It  is  claimed 
that  80  per  cent  may  remain  well  under  such  condition  v. 

Since  the  introduction  of  the  Harrison  Law,  it  is  more  than  ever 
desirable  to  help  patients  free  themselves  from  this  addiction.  The 
drug  is  not  easily  obtained  and  recurrences  are,  therefore,  not  so 
frequent. 

After  all,  abstinence  from  the  use  of  narcotic  drugs  depends  upon 
the  individual.  If  there  is  no  inborn  force  of  character,  there  is  but 
little  hope  of  a  cure.  "'The  human  zero,  plus  or  minus  drug  addic- 
tion ecpials  zero ! ' ' 

The  statements  made  concerning  the  treatment  of  opium  and  mor- 
phine apply  equally  well  to  cocaine.  The  Town  method  is  particularly 
indicated  here.  Strychnine  as  used  in  opium  eases  is  very  desirous 
here,  but  some  form  of  digitalis  should  be  given  along  with  this  drug. 
Following  the  treatment,  the  patients  require  a  much  longer  period 
in  which  to  build  up  physically,  than  do  the  morphinists,  and  hence, 
really  require  longer  attention.  The  treatment  should  be  carried  out 
before  any  operative  interference,  but  if  this  is  not  possible,  the  prog- 
nosis is  very  little  affected  because  of  the  fact  that  the  patient  is  a 


DRUG   ADDICTION    IX    SURGICAL   PATIENTS  209 

drug  addict.  As  with  morphine,  no  strenuous  efforts  should  be  made 
to  cure  the  habit  until  late  in  a  successful  surgical  convalescence. 

The  treatment  of  chloralism,  trionalism,  sulphonalism  and  other 
narcotic  drug  habits  is  carried  out  along  the  same  general  lines  of 
elimination  and  withdrawal  of  the  drug.  In  each  and  every  case 
every  hygienic  measure  is  employed  to  put  the  system  in  normal  tone. 
The  permanence  of  any  result  depends  upon  the  patient  himself  and 
upon  his  association. 

Tobacco,  coffee,  and  tea  are  so  commonly  abused  that  patients  with 
such  habits  are  operated  upon  as  a  matter  of  course.  The  ordinary 
use  of  either  of  these  drugs  does  not  necessarily  increase  the  surgical 
risk,  but  the  continued  abuse  of  any  one  of  them  over  a  long  period 
of  time  may  cause  serious  untoward  symptoms,  when  the  additional 
strain  of  an  operation  is  superimposed. 

Tobacco  is  a  poison,11  the  excessive  use  of  which  may  produce  pal- 
pitation, irregular  action  of  the  heart,  paroxysms  of  asthma,  angina 
pectoris,  tremor,  muscular  weakness,  loss  of  sleep,  sometimes  symp- 
toms of  tabes,  amblyopia,  gastric  disturbances,  chronic  catarrh  of  the 
pharynx  and  larynx,  neuralgias  and  headache.12  The  minimum 
amount  of  this  weed  should  be  used,  if  any  is  used  at  all,  during  the 
preoperative  treatment ;  there  must  be  careful  etherization  during 
the  operation,  and  none  of  this  luxury  is  allowed  during  the  convales- 
cence unless  the  desire  to  continue  the  habit  is  so  great  as  to  cause 
nervousness  and  wakefulness,  in  which  event  the  least  amount  that 
will  satisfy  the  patient's  need,  is  permitted. 

Coffee  and  tea  owe  their  effects  to  the  caffeine  which  is  contained 
in  each;  one  cupful  of  either  beverage  contains,  according  to  Cush- 
ny>  1/4  t°  3  grains  of  this  alkaloid.  The  action  of  caffeine  on  the 
body  is  chiefly  stimulative.13  The  brain  and  the  whole  nervous  sys- 
tem are  affected.  The  heart  and  the  musculature  throughout  the 
body  are  likewise  influenced.  Moderate  closes  cause  a  rise  in  the 
blood  pressure.  Eespiration  is  increased  in  rate,  and  metabolism  is 
considerably  stimulated.  Gastric  juice  is  increased  by  ingestion  of 
coffee,  though  tea  has  an  opposite  effect.14  In  addition  to  caffeine, 
tea  also  contains  tannic  acid  and  because  of  this,  may  produce  in- 
digestion and  constipation.  Sudden  deprivation  of  either  beverage 
may  be  followed  by  extreme  nervousness  and  wakefulness  in  patients 
long  addicted  to  their  use  in  excess.  Headache  is  a  common  symptom 
following  the  withdrawal  of  either  drug.  Such  patients  should  be 
given  much  less  than  the  accustomed  amount  of  the  beverage  when 
preparing  for  an  operation.     The  danger  of  the  operative  procedure 


210  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

is  not  enhanced  or,  at  least,  but  slightly ;  though  during  the  conva- 
lescence, the  minimum  amount  of  coffee  should  be  permitted. 

In  highly  nervous   cases   and   especially   in   toxic   goiter  patients, 
no  stimulating  beverage  is  allowed  at  all. 

Bibliography 

iBishop:     Am.  Jour.  Surg.,  1915,  xxix,  435. 
2Kennedy:     Ibid.,  1914,  c,  20. 
sPowcrs:     Wisconsin  Med.  Jour.,  1915,  xiii,  431. 
4Lichten stein :     New  York  Med.  Jour.,  1914,  c,  962. 
sBishop:     New  York   Med.  Jour.,  1915,  ci,   402. 

ePettey:      Ibid.;    also  The  Narcotic  Drug  Diseases  and   Allied   Ailments,   Phila- 
delphia, 1913,  F.  A.  Davis  Co. 
TTown :      Hare;    Practical    Therapeutics. 
8Lambert:     Jour.  Am.    Med.  Assn.,   1913,   lx,   1933. 
aErlenmeyer:     Cushny 's  Pharmacology  and  Therapeutics,  1915,  Philadelphia,  Lea 

&  Febiger. 
loSeeleth:      Jour.  Am.  Med.   Assn.,   1916,  lxvi,  860. 
nWhite:      Southern  Med.  Jour.,  1915,  xiii,  17. 
isMusser  and  Kelley:     Practical  Treatment,  1917,  Philadelphia,  W.  B.  Saunders 

Co. 
ispincussohn :     Miinchen.   med.   Wchnschr.,    1906,   No.   2(i. 

14Sajous:     Analytic  Cyclopedia  Practical  Medicine  1916,  Philadelphia,  F.  A.  Davia 
Co.,  iii,  513. 


CHAPTER  XXVI 

ALCOHOLISM  IN  ITS  EELATIOX  TO  SURGERY 
By  Q.  F.  McKittrick,  St.  Louis,  Mo. 

Alcoholism  is  found  in  all  walks  of  life,  and  occurs  in  all  classes  of 
society — a  condition  as  needless  as  it  is  harmful,  also  one  which  pre- 
sents serious  difficulties  in  the  way  of  the  successful  outcome  of  a 
surgical  convalescence.  Just  why  this  detrimental  condition  must 
remain  a  factor  even  in  the  present  day  surgery,  is  a  secret  which  the 
chronic  alcoholic  in  many  instances  alone  can  divulge.  The  reasons 
for  drinking  are  varied.  The  habit  is  begun  early  in  life,  usually  be- 
fore the  age  of  30.1  but  very  commonly  it  is  given  up  between  40  and 
65. 2  Unfortunately,  those  who  yield  to  its  clutches  and  become  its 
slaves  are  usually  of  the  neurotic  type.  In  such  patients,  an  operation 
itself  being  very  serious,  alcohol  does  its  greatest  damage.  The  two 
most  important  classes  of  alcoholic  cases  which  present  themselves 
for  surgical  treatment  are  the  constant  daily  drinkers,  who  must  have 
their  regular  portion,  and  the  periodic  drunkards  who  between  times 
probably  do  not  touch  a  drop  of  liquor.3  It  is  a  matter  of  common 
knowledge  that  patients  who  do  not  drink  get  along  a  great  deal  bet- 
ter than  do  the  alcoholics  during  surgical  procedures.  The  temperate 
alone  possess  calmness  of  body  and  mind  and  the  ability  to  respond 
promptly  to  stimulation  which  so  often  obviates  shock.  Such  a  resist- 
ance to  the  deleterious  effects  of  an  operation  is  not  possessed  by 
those  whose  vital  powers  have  long  been  driven  by  the  overstimulating 
effect  of  intoxicating  liquor. 

The  observation  of  Cheever.4  that  such  patients  undergo  a  ■"laborious 
and  excitable  etherization"*  is  a  common  experience  among  all  opera- 
tors. This  is  not  surprising  when  one  considers  that  once  confirmed  in 
the  use  of  alcohol,  an  individual  goes  the  downward  road  that  leads 
to  complete  mental  and  physical  decay.3  The  damaging  evidences 
of  the  poison  are  presented  in  every  organ  of  the  body.  The  brain 
and  meninges  at  times  become  edematous,  the  cells  throughout  the 
nervous  system  degenerate,  the  arteries  become  sclerotic  and  the  veins 
dilate,  all  of  which  leads  to  a  '"labored  and  slow  circulation.'''  The 
tissues  throughout  the  organism  become  hardened  and  thickened, 
which  necessarily  delays  absorption,  and  the  natural  activities  of 
various  cellular  functions.     There  is  fatty  degeneration  of  the  paren- 

211 


212  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

chyma  of  the  liver,  pancreas,  and  kidneys,  in  addition  to  fibrous 
changes;  the  mucosa  of  the  pharynx  and  stomach  become  thickened 
and  hyperplastic.  Such  pathologic  conditions  give  rise  to  symptoms 
such  as  tremor,  gastric  irritability,  enfeeblement,  physical  and  men- 
tal, which  gradually  grows  worse  as  the  years  pass;  also  increased 
blood  pressure  and  albuminuria. 

Such  a  condition  is  certainly  detrimental  to  the  patient  who  is 
suddenly  brought  to  face  accidents  or  operative  procedures.  Even 
in  selected  operative  cases,  no  amount  of  preparation  can  repair  the 
structural  damage  already  wrought,  and  the  patient  is  subjected  to 
added  danger  in  consequence.  The  daily  tippler  who  on  rare  occa- 
sions only  gets  drunk,  is  a  much  better  risk  than  the  man  who  peri- 
odically gets  intoxicated. 

The  prognosis  Eor  the  former  is.  however,  much  more  grave  if  the 
operation  be  accompanied  by  severe  hemorrhage  or  shock,  since  the 
resistance  is,  without  doubt,  more  or  less  lowered  from  the  continued 
use  of  alcohol.  The  periodic  drunkard  presents  a  somewhat  different 
problem  and  more  serious  risk.  Not  in  the  habit  of  drinking  daily 
and  probably  not  thinking  about  the  necessity  of  preparing  himself 
with  his  stimulant,  he  fails  to  make  his  weakness  known,  is  admitted 
to  the  hospital,  no  alcohol  is  given,  and  he  is  operated  upon  for  some 
trivial  condition  it  may  be.  Bu1  il  apparently  <\<»^  not  matter  how 
insignificant  or  how  serious  the  operation  may  be,  it  is  the  alcoholic 
condition  of  the  patient  which  makes  the  surgical  procedure  hazard- 
ous. The  trauma  of  the  operation  added  to  his  already  altered  con- 
lit  ion.  breaks  down  what  defenses  he  maj   have. 

For  a  few  days  he  may  do  well,  but  a  prolonged  abstinence  from 
alcohol  causes  him  to  become  restless,  nervous,  and  exceptionally 
keen  to  happenings  around  him;  small  and  insignificant  acts  of  others 
are  irritating  to  him.  Sleep  is  very  poor  and  he  has  hallucinations 
which  seem  to  him  dreams  and  disturb  him.  although  he  knows  they 
are  unreal.  For  several  days'  the  patient  may  be  concerned  about 
himself;  there  may  lie  a  distressed  feeling  in  the  epigastrium  or  sing- 
ing in  his  ears  which  at  times  may  seem  to  be  voices.  He  may  com- 
plain of  dizziness;  tremor  develops  in  his  hands,  and  his  tongue 
trembles.  Finally,  if  nothing  is  clone  to  avert  the  Calamity,  delirium 
tremens  develops. 

Delirium  Tremens 

It  is  common  knowledge  that  delirium  tremens  is  apt  to  develop  in 
regular  drinkers  following  operation  or  with  the  beginning  of  pneu- 
monia.    It  is  most  common  in  emergency  operations  after  injuries, 


ALCOHOLISM   IN   ITS   RELATION    TO    SURGERY  213 

in  patients  who  are  chronic  drinkers.  The  patient,  however,  may 
never  have  been  in  the  habit  of  becoming  actually  drunk. 

Following  the  operation  or  injury,  the  patient  has  an  almost  sleep- 
less night.  The  brief  periods  of  sleep  which  may  occur,  are  filled 
with  horrible  dreams.  Morning  finds  him  restless,  nervous,  tired, 
suspicious  and  apprehensive,  the  appetite  is  gone  and  he  may  or  may 
not  crave  alcohol.  Later  on  during  the  day,  hallucinations  like  the 
nightmares  of  the  night  come  to  him,  in  spite  of  the  fact  that  he  is 
wide  awake.  He  may  succeed  in  fighting  them  down  for  a  few  hours, 
but  ultimately  he  is  overpowered  and  horrors  reign  supreme. 

In  the  usual  form  of  the  disease,  recognizable  symptoms  appear 
after  two  days  or  more.  The  patient  is  at  first  quiet,  submissive,  and 
his  condition  may  even  resemble  mild  shock.  His  mind  is  change- 
able ;  impressions  last  but  a  few  moments  and  frequently  the  patient 
fears  that  he  is  going  to  die.  He  is  anxious  to  comply  with  the  wishes 
of  his  doctor  or  nurse,  carries  out  orders,  but  sometimes  with 
violence.  He  is  restless  and  nervous,  tries  to  get  out  of  bed,  and  in- 
sensible to  the  pain  it  may  cause  him,  attempts  to  walk  around  in 
an  effort  to  get  away  from  the  hallucinations  of  fear,  persecution,  or 
what  nots,  which  are  torturing  him.  His  mind  is  in  a  chaos  of  ever- 
changing  ideas.  He  talks  incessantly,  the  subject  of  the  conversation 
with  himself  being  a  combination  of  delirious  ideas  and  fanciful  no- 
tions of  things  and  people  about  him.  He  recognizes  his  friends  for 
a  while,  but  in  the  uncontrollable,  vivid  and  dreadful  hallucinations 
he  soon  ceases  to  know  anything  or  anybody,  and  regards  all  people 
and  objects  as  taking  part  in  his  persecution  and  final  destruction. 
He  may  fight  or  injure  himself  and  others  in  his  violent  efforts  to 
evade  torment.  In  his  panic,  he  moans,  mutters,  curses,  cries,  shouts 
or  prays.  He  looks  fearfully  about,  suspicious  of  everybody  and 
everything,  and  listens  as  though  he  heard  sounds  or  voices.  He 
sees  objects  which  appear  multiple.  These  take  the  forms  of  various 
animals,  such  as  snakes,  rats,  and  dogs.  In  this  stage,  the  patient  is 
obviously  physically  sick.  He  is  entirely  sleepless,  perspires  freely, 
the  limbs  tremble,  the  head  shakes,  and  the  muscles  of  the  face  twitch, 
the  pupils  are  widely  dilated  and  the  tongue,  which  is  heavily  coated, 
quivers.  As  the  delirium  increases,  the  tremor  abates  somewhat. 
Finally,  after  many  hours,  even  clays  of  torture,  the  patient  becomes 
stuporous,  the  heart  rate  gradually  diminishes,  and  after  a  period  of 
weariness  and  relative  quiet,  the  patient  falls  into  a  deep  sleep  which 
lasts  from  twelve  to  thirty  hours.  Following  this,  he  becomes  cogni- 
zant of  his  surroundings,  the  hallucinations  are  gone,  and  the  orienta- 
tion is  complete,  still  the  mental  condition  is  not  quickly  restored  and 


211  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

for  several  days,  the  patient  is  unable  to  correctly  concentrate  his 
thoughts. 

In  some  men  there  is  a  reappearance  of  the  delirium  during  the 
night,  while  during  the  day  they  remain  free.  In  such  patients,  any 
excitement  causing  mental  exhaustion  may  bring  back  some  of  the 
hallucinations. 

A  good  routine  preventive  treatment  has  been  suggested  by  Max- 
well,7 it  consists  in  giving  a  dram  of  paraldehyde  in  an  ounce  of 
whiskey  every  four  hours  alternating  with  15  grains  of  veronal.  Such 
treatment  is  carried  out  on  every  patient  where  there  is  danger  of  de- 
lirium tremens,  and,  particularly,  in  those  alcoholics  in  whom  an  op- 
eration is  performed  without  adquate  preparation.  It  is  kept  up  un- 
til a  sound  sleep  which  lasts  twelve  liours  is  secured.  Just  as  soon 
as  the  patient  can  go  to  sleep  readily,  the  sedatives  are  stopped.  It 
usually  takes  about  two  days  to  accomplish  this.  The  treatment  is 
not  commenced  for  eight  hours  after  an  operation  because  of  the  con- 
dition of  the  stomach. 

In  alcoholic  cases.  mos1  thorough  elimination  by  kidneys,  bowels, 
and  skin  is  continued  for  two  or  three  days  before  the  operation  if 
there  is  time  for  such  preparation.  In  addition,  forced  feeding  with 
large  amounts  of  liquids  is  persisted  in. 

The  treatment  must  be  symptomatic.8  These  patients  have  often 
subsisted  so  long  on  alcohol  with  inadequate  food  that  degenerative 
change  in  the  heart  muscle,  arteries,  stomach,  and  other  organs  have 
developed,  hence  danger  is  not  so  much  in  the  delirium  itself  as  in 
the  diseased  condition  of  vital  organs  of  the  body.  In  young  alco- 
holics, the  alcohol  should  be  withdrawn,  but  in  weak  or  elderly  pa- 
tients, it  can  be  gradually  reduced  only.  The  stomach  should  be 
washed,  if  the  surgical  condition  permits  it.  and  a  generous  dose  of 
epsom  salts  left  in  the  stomach.  The  patient  is  put  into  a  warm  bath, 
or  else  sweating  is  obtained7  by  means  of  the  hot-air  bath  or  hot 
pack.  Potassium  citrate  25  grains,  is  given  every  four  hours,  as  are 
large  amounts  of  water  by  mouth,  by  rectum,  and  under  the  shin 
to  aid  the  eliminative  power  of  the  kidneys.  It  must  not  be  lost 
sight  of,  however,  that  the  patient  is  to  lie  treated  as  one  having  a 
degenerated  heart  muscle  and  no  eliminative  measure  should  be  car- 
ried out  which  would  likely  cause  sudden  dilatation.  The  blood 
pressure  must  be  watched  closely  and  stimulants  administered  to 
the  heart.  Pituitrin  is  useful  fur  this  purpose.  Strong  coffee  can 
be  administered  instead  of  the  pure  caffeine.  Atropine  is  valuable 
in  marked  depression  with  pulmonary  edema,  cold  and  clammy  skin. 
and  it  may  also  lessen  the  craving  for  alcohol. 


ALCOHOLISM   IN   ITS   RELATION    TO    SURGERY  215 

In  mild  attacks,  the  delirium  may  be  controlled  by  paraldehyde, 
1  or  2  drams  repeated  every  hour  if  necessary.  Chloral  in  large 
doses,  30  grains  or  more  may  be  given  per  rectum  by  olive  oil. 

Osier  recommends  a  mixture  of  morphine  (%  grain)  with  chloral 
(15  to  30  grains)  and  to  these  are  added  tincture  hyoscyamus  (% 
dram)  tincture  ginger  (10  minims)  and  tincture  of  capsicum  (3 
minims)  water  q.  s.,  %  ounce.  This  mixture  is  given  every  hour  if 
necessary.  The  delirium  is  not  cut  short,  but  sleep  is  secured  for 
some  hours,  which  gives  the  needed  rest  to  the  overworked  heart. 

Intramuscular  injections  of  ergot  are  also  recommended.  The  solid 
extract  is  dissolved  in  one  ounce  of  sterile  water.  Thirty  drops  of 
this  solution  are  given  every  two  to  four  hours.  It  tends  to  lessen 
the  various  congestions  and  bring  about  a  better  equilibrium  of  the 
circulation. 

Recently,  Leonard9  has  reported  the  results  of  giving  intraspinal 
injections  of  magnesium  sulphate  in  12  cases  of  delirium  tremens. 
Lumbar  puncture  was  done,  and  varying  quantities  of  the  cerebro- 
spinal fluid  (10  to  40  c.c.)  withdrawn,  depending  on  the  pressure. 
Following  this,  1  c.c.  of  a  25  per  cent  solution  of  chemically  pure 
magnesium  sulphate  to  every  25  pounds  of  body  weight  was  intro- 
duced through  the  lumbar  puncture  needle  by  means  of  a  syringe. 
The  treatments  were  given  with  the  patient  in  sitting  posture,  but 
afterward  he  was  put  into  the  semirecumbent  position.  These  pa- 
tients required  constant  attention  for  twenty-four  hours  following  the 
injection.  Seven  developed  a  paraplegic  state  in  which  they  lost  con- 
trol of  both  sphincters.  The  condition  appeared  within  forty-eight 
hours.  Five  cases  had  retention  of  urine  with  weakness  in  lower 
limbs  and  lessened  reflexes.  The  temperatures  in  these  patients  rose 
to  101°  to  103°. 

Since  the  mortality  is  so  high  among  such  cases  and  since  so  little 
is  accomplished  at  times  with  sedatives,  Leonard  feels  that  one  is 
justified  in  using  this  treatment.  The  delirium  and  restlessness  sub- 
side very  soon  following  the  injection,  and  the  patient  is  restored  to 
normal  within  twenty-four  hours. 

Food  should  be  given  every  two  or  three  hours  during  the  period 
of  delirium  or  when  the  patient  is  awake.  Under  no  circumstances, 
disturb  him  if  asleep.  A  little  eggnog  along  with  the  food  may  be 
given  in  all  cases,  but  in  the  aged  or  very  weak  patients,  this  is  im- 
perative. 

Restraint  is  always  bad  form.  If  it  is  possible  to  have  two  attend- 
ants to  watch  the  patient  and  keep  him  in  bed,  this  is  better  than 
the  use  of  any  artificial  means.    If  necessary,  these  remedies  must  be 


216  AFTER-TREATAIEXT    OF    SURGICAL   PATIEXTS 

employed.  However,  every  available  means  must  be  exhausted  to 
assure  the  patient  and  to  gain  his  confidence  before  any  attempt  at 
force  is  made. 

During  the  convalescence,  stomachics,  such  as  ginger,  capsicum 
or  mix  vomica  may  be  given.  Frequent  warm  baths  and  careful  at- 
tention to  the  bowels,  massage,  early  sitting  up,  calisthenics,  fresh  air 
and  sunshine  will  enable  the  patient  to  leave  the  hospital  a  week  or 
ten  days  after  his  attack  of  delirium  if  the  nature  of  his  operation 
permits. 

Bibliography 

iDana:     Inebriety,  Med.  Rec.  New  York,  .July. 

2Kerr:     Alcoholism  and  Drug  Habits,  Twentieth  Century  Practice  of  Medicine,  iii. 

3Crandon  and  Ehrenfried :     Surgical  After-treatment.  Philadelphia,  1012,  W.   B. 

Saunders   Co. 
4Cheever:     Boston  Med.  and  Surg.  Jour..  1893,  cxviii,  253, 
oLegraine:     Tuke's  Diet,  of  Psych.  Med. 

60sler-McCrae :     Modern  Medicine,  Philadelphia.  1914,  Lea  &  Febiger,  ii.  410. 
7Maxwell:     St.  Paul  Med.  Jour.,  1914,  xvi,  664. 
sOsler-McCrae :     Modern  Medicine,  p.  508. 
^Leonard:     Jour.  Am.   Med.  Assn.,   1916,  lxvii,   509. 
The  following  references  were  also  consulted: 
Carter:      Med.  News,  March,  Is!1". 
Sommer:     Diagnostick  der   Geisteskranckeiten. 
White:     Reference  Handbook  of  Medical  Science.  1902,  v.  81. 


CHAPTER  XXVII 

POSTOPERATIVE  PSYCHOSES 
By  0.  F.  McKittriek,  St.  Louis,  Mo. 

A  surgical  operation  is  almost  always  considered  a  tragedy.  It 
should,  in  compensation  for  the  mental  and  physical  suffering  in- 
curred, be  followed  without  delay  by  a  period  of  comfort  and  of  good 
health.  It  really  becomes  a  tragedy  when  happiness  does  not  appear, 
but  instead  new  dangers  and  discomforts  present  themselves  as  a  re- 
sult of  the  operation  to  increase  the  gloom,  and,  finally,  the  reason 
becoming  dethroned,  the  fruits  of  surgical  labor  are  suddenly  snatched 
away. 

It  has  long  been  known  that  mental  disturbances  may  follow  oper- 
ations. As  early  as  the  sixteenth  century  Pare  considered  a  "spirit- 
ual calm,"  essential  to  the  future  well  being  of  patients  about  to  un- 
dergo one.  It  was  not  until  the  beginning  of  the  nineteenth  century, 
however,  that  postoperative  mental  excitation  was  first  described  by 
Dupuytren  who  called  the  condition  "delirium  nervosum."  A  few 
decades  later,  Herzog  and  Siehel,  and  many  others  reported  cases  of 
insanity  following  eye  operations.  In  1865,  Van  Courtney  reported 
the  first  case  of  insanity  following  ovariotomy.  Fifteen  years  later, 
Lcjsen  and  Furstner  cited  such  an  instance  following  hysterectomy. 
Since  that  time  many  observations  have  been  made  on  the  subject. 
Such  papers,  however,  have  appeared  sporadically,  and  both  in  Amer- 
ica and  abroad,  these  are  for  the  most  part  fragmentary,  the  authors 
merely  reporting  a  case  here  and  there. 

Mental  derangement  of  almost  every  degree  and  character  has  been 
described  following  surgical  operations.  It  occurs  most  frequently  in 
adults;  in  the  female  more  commonly  than  in  the  male.  Neither 
children  nor  the  aged  escape,  though  the  usual  period  of  life  in  which 
this  serious  complication  makes  itself  known,  is  between  thirty-five 
to  forty-five  years.1  It  is  hardly  possible  to  say  just  how  often  post- 
operative psychoses  will  occur.  Many  psychoses  do  not  make  their 
appearance  until  after  weeks  or  months.  In  the  series  of  forty  cases 
reported  by  Kelly,  the  majority  of  the  symptoms  occurred  between 
the  second  and  tenth  days.  In  eight  instances  they  began  almost 
immediately  after  the  operation.  In  others,  they  did  not  appear  for 
one  month.     Out  of  every  1000  patients  who  undergo  laparotomy, 

217 


218  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

four  will  go  insane,  according  to  Da  Costa.2  Of  5000  insane  patients, 
Dewey  found  only  3  whose  minds  were  sound  before  the  operation. 
Of  the  milder  mental  disturbances  which  follow  operation.  Kelly 
found  50  after  13,000,  while  Mitchell  reported  31  instances  in  344 
patients. 

Psychoses  arc  as  common  after  mild  as  after  severe  operations. 
The  anesthetic  does  not  seem  to  make  much  difference,  the  condition 
occurring  alike  after  ether,  chloroform,  or  gas  anesthesias.  Instances 
occur  even  after  local  anesthesia  as  reported  by  Selberg3  and  also  by 
Grekow.4  It  seems  that  most  of  the  cases  reported  in  the  literature 
followed  gynecologic  or  ophthalmologic  operations.  Picque5  very 
strongly  insists  that  postoperative  mental  aberrations  are  no  more  apt 
to  follow  operations  of  this  character  than  those  on  other  parts  of 
the  anatomy.  Indeed.  Rohe  found  that  out  of  196  cases,  65  followed 
genital  and  35  followed  cataract  operations,  while  96  appeared  as  a 
result  of  operations  on  other  parts  of  the  body.  Abdominal  opera- 
tion in  which  the  ovaries  are  not  involved  do  not  particularly  pre- 
dispose to  mental  disturbances.  However,  removal  of  the  ovaries 
or  testicles  is  peculiarly  provocative  of  this  condition. 

A.S  to  the  forms  of  postoperative  insanity,  it  is  claimed  that  there 
is  no  one  type.  Clinically  the  term  includes  those  varieties  of  mental 
aberration  which  are  related  to  each  other  only  in  so  far  as  they  occur 
in  a  surgical  convalescence.  The  condition  ranges  from  a  mild  transi- 
tory mental  disturbance  to  that  of  an  incurable  maniacal  state.     Some 

authors  make   no  attempt    to  determine  the   s] ial  form  of  disease 

which  has  presented  itself.  Urbach6  classified  his  five  cases  following 
106  gall  bladder  operations  as  "acute  hallucinatory  confusional  in- 
sanity." Others  have  noted  melancholia,  stupor,  delusional  state. 
hysterica]  excitement,  morbid  fears,  delusions,  hallucinations,  etc.. 
but  probably  the  most  common  form  is  acute  confusional  insanity. 
Tt  is  characterized  by  confusion  of  thought  and  incoherence  of  speech, 
delirium,  at  times  delusions  and  hallucinations,  alternating  with  pe- 
riods of  stupor  following  the  mental  excitation. 

There  are  many  factors  connected  with  a  surgical  operation  which 
may  prove  fruitful  as  an  exciting  cause  for  insanity  which  appears 
at  times  during  the  convalescence.  The  patient  may  have  suffered 
from  severe  pain,  fear,  sleeplessness  or  exhaustion.  lie  worries  more 
or  less,  and  the  operation  is  performed  under  a  general  anesthetic 
which  leaves  him  unusually  toxic.  There  is  some  loss  of  blood,  and 
shock  may  appear  after  the  awakening  from  anesthesia.  There  is  post- 
operative pain  with  possibly  attending  insomnia,  anxiety,  concern,  and 
even  homesickness  which  is  the  last  straw. 


POSTOPERATIVE   PSYCHOSES  219 

There  is  a  predisposition,  either  hereditary  or  acquired  in  all  cases 
of  postoperative  insanity;2  the  operation  and  all  that  is  associated 
with  it  being  only  an  exciting  element  which  completes  the  over- 
throw of  the  unstable  and  predisposed  nervous  system.  Histories7 
are  not  always  reliable,  since  many  patients  are  averse  to  giving  cor- 
rect details  concerning  this  subject.  Many  observers  believe  that  these 
unfortunate  patients  were  in  danger  of  insanity  before  the  operation 
and  would  have  probably  gone  insane  anyway,  sooner  or  later,  when 
exposed  to  the  chances,  worries  and  changes  of  life,  even  had  no  opera- 
tion been  performed.  Da  Costa  definitely  states  that  a  normal  healthy 
individual  will  probably  never  go  insane  following  any  surgical  pro- 
cedure unless  it  involved  the  brain,  removal  of  the  testicles  or  the 
ovaries.  Berkley8  found  that  60  to  70  per  cent  of  those  patients  now 
in  asylums  show  such  a  history,  while  Kaller,9  studying  the  histories 
of  2273  patients  in  Switzerland  noted  78  per  cent  with  tainted  an- 
cestry. 

Two  very  important  factors  concerned  with  these  mental  states  are 
fear  and  worry.  There  is  evidence  in  abundance  to  show  that  fear 
can  produce  all  sorts  of  disturbances  in  the  human  mechanism.  The 
patients,  it  is  true,  who  come  to  operation,  are  usually  outwardly 
calm,  heroically  firm  and  determined,  some  even  happy  at  the  pros- 
pect of  being  freed  of  their  disease,  but  if  one  could  fathom  the  in- 
nermost workings  of  their  minds,  in  many  instances,  one  would  be  as- 
tonished at  the  damage  which  this  one  factor  alone  has  wrought,  the 
harm  having  been  done  long  before  the  time  set  for  the  operation. 

In  patients  not  predisposed  to  mental  disorders,  either  by  acquired 
weakness  or  by  heredity,  the  danger  of  permanent  mental  disarrange- 
ment is  not  so  great  as  in  those  not  so  handicapped.  The  operation 
over,  the  gloom  which  surrounds  such  patients  lifts,  and  the  worri- 
ment  promptly  ceases.  In  individuals,  however,  predisposed  to  in- 
sanity, there  may  be  no  rally  at  all  even  after  an  operation  which 
promises  a  life  free  from  the  original  cause  of  the  trouble,  but  the 
condition  passes  from  one  of  worry  to  one  of  actual  mental  unbalance 
which  may  deepen  into  an  insanity  incurable  by  any  means  within 
our  reach. 

The  prognosis  in  the  first  class  of  cases  mentioned  above  is  very 
favorable,  but  in  the  second  class,  too  favorable  an  outcome  must 
not  be  expected.  The  prognosis  in  general  according  to  MacPhail10 
is  60  per  cent  recovery,  while  Werth11  and  Ellbery  claim  only  50 
per  cent.  Fillebrown12  considers  the  outlook  very  bad  for  any  pa- 
tient in  whom  the  mental  disturbance  is  anything  but  transitory.  In 
older  individuals,  especially  those  suffering  from  serious  organic  dis- 


220  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

ease,  particularly  syphilis,  a  grave  prognosis  is  always  to  be  given. 

Crile  and  his  associates  have  shown  good  anatomic  reasons  why 
such  conclusions  are  inevitable.  He  finds  that  patients  and  animals, 
which  are  victims  of  nervous  and  physical  assaults,  suffer  practically 
the  same  degenerative  changes  in  the  brain  cells.  These  cells  increase 
considerably  in  size,  and  the  cell  membrane  becomes  broken,  causing 
distortion  of  its  shape.  The  reaction  to  Xissl's  stain  is  character- 
istic. An  increased  amount  of  this  stain  is  absorbed  at  first,  then  as 
the  degree  of  damage  is  increased,  the  reaction  to  the  stain  diminishes, 
so  that  in  the  final  stages  little  or  no  staining  is  found. 

The  nucleus,  nucleolus  and  cell  body  having  been  broken  down,  a 
mere  mass  of  cytoplasm  alone  remains  and  is  incapable13  of  regenera- 
tion. The  number  of  such  cells  destroyed  indicate  the  severity  of  the 
lesion.  Crile  and  his  coworkers  have  found  that  the  brain  cells  re- 
spond in  the  same  way  when  subjected  to  overwork,  infections,  drug 
poisons,  shock,  fear  or  anxiety. 

Just  how  the  exciting  factors  bring  about  such  changes  in  the  nerve 
cells  can  not  be  entered  into  here.  A  more  thorough  study  in  recent 
years  of  disorders  following  operations  is  proving  its  importance  in 
that  they  are  rapidly  becoming  an  avoidable  calamity.14 

It  goes  without  saying  that  before  any  operation,  the  patient  should 
be  known  to  the  surgeon.  A  thorough  history  is  almost  indispensable. 
If  there  is  insanity  in  the  family  or  if  the  patient  himself  has  a  his- 
tory of  having  been  temporarily  insane,  an  operation  certainly  ex- 
poses him  to  very  distinct  danger  of  another  attack.  None  but  the 
most  urgent  operations  are  justifiable  in  these  cases  and  the  risk 
should  always  be  explained  to  the  family.  In  highstrung  or  nervous 
individuals,  and  most  patients  become  nervous  in  view  of  an  impend- 
ing operation,  the  surgeon  must  maintain  a  constant  attitude  of  op- 
timism and  encouragement,  he  must  never  lose  sight  of  the  fact  that 
the  patient  is  to  be  inspired  with  confidence.  Neurasthenics,  if  such 
patients  exist,  are  always  bad  risks  and  operations  on  them  should 
be  avoided  if  possible. 

If  the  patient  develops  symptoms  of  this  dreaded  condition  after 
every  effort  has  been  carried  out  to  lessen  worry,  fear,  surgical  trauma, 
etc.,  treatment  must  be  instituted  at  once. 

Probably  it  would  be  of  importance  in  this  connection  to  mention 
the  following  case  history: 

No.  605(>,  Miss  J.  C.j  29.  saleslady,  two  sisters  insane.  Patient  was  admitted 
for  goiter  operation.  Swelling  in  the  neck  had  started  5  years  ago  and  gradually 
increased.  Xo  symptoms  of  toxic  goiter  until  one  year  ago  when  tremor,  nervous- 
ness, palpitation,  and  tachycardia  were  noted.  These  had  gradually  increased 
until   she  presented  a   typical   picture.     She   complained   principally   of   headache 


POSTOPERATIVE    PSYCHOSES 


221 


which  had  been  more  or  less  present  during  the  past  two  months,  but  showed  no 
other  symptoms  worthy  of  notice,  except  the  fact  that  she  was  peculiar  and  did 
not  always  answer  questions  willingly. 

She  was  put  to  bed,  a  pitcher  of  water  was  placed  at  her  side  and  at  least  1 
glassful  every  hour  was  given  her  throughout  the  day.  Sodium  citrate  (20 
grains)  with  one  dram  of  sodium  bicarbonate  were  given  three  times  a  day 
for  the  first  two  days.  The  headache  was  stopped  with  aspirin  (10  grains),  still 
she  was  unhappy  and  worried.     Very  little  shock  followed  thyroidectomy. 

The  convalescence  continued  uninterrupted  and  the  patient's  mind  was  clear 
for  four  days  when   she  became  morose,  despondent,   and  wished  to   die.     Dux- 


Fig.   28. — A  method  of  confining  the  hands  used  at  the  Minnesota   State  Hospital,   Rochester. 


ing  this  day  and  following  night,  she  was  irrational,  worried,  had  frequent  cry- 
ing spells,  refused  to  answer  questions,  and  complained  of  headache. 

Early  the  next  morning  800  e.c.  of  salt  solution  were  given  hypodermically, 
were  repeated  in  six  hours.  She  slept  all  the  following  night  but  the  next 
morning  in  addition  to  previous  symptoms,  became  exceedingly  stubborn  and  re- 
fused to  eat.  During  the  next  day,  she  slipped  out  of  bed  and  roamed  over  the 
hospital.  She  was  brought  back  and  carefully  watched  while  10  grains  of  aspirin 
with  one  grain  of  codeine  stopped  her  headache  and  gave  her  a  good  night's 
sleep.     Next  morning  she  insisted  upon  getting  out  of  bed,  complained  bitterly 


222  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


Fig.  29-A. — A  simple  method  of  tying  the  feet,  which  allows  the  patient  to  sit   up  in  bed. 


Fig.  29-B. — A  useful  leg  cuff  and  strap   which   permits  i_atient  to  sit  up  in  bed. 


POSTOPERATIVE   PSYCHOSES 


223 


of  mistreatment,  started  to  cry,  talked  irrationally,  and  remained  very  morose 
and  refused  food.  Two  days  later,  2000  e.c,  of  water  were  given  hypodermieally 
at  one  time,-  which  at  once  stopped  the  mental  excitation,  the  patient  remained 
quiet  throughout  that  day,  and  slept  well  that  night. 

The  following  morning,  she  expressed  fear  of  having  to  go  to  the  asylum 
with  her  sisters,  and  later,  tried  to  escape  from  the  hospital,  making  it  necessary 
to  strap  her  wrists,  Fig.  28.  Her  breakfast  was  given  her  by  force,  after 
which  she  became  very  obedient,  ate  her  meals  willingly,  did  not  object  to  the 
straps,  and  the  wouud  healed  perfectly.  On  the  ninth  day  the  straps  were  re- 
moved and  at  the  first  opportunity  she  got  out  of  bed  again,  wandered  about, 
and  became  so  violent  and  unmanageable  that  in  addition  to  strapping  her  hands, 
it  was  also  necessary  to  strap  her  feet,  (Figs.  29A  and  29B.)  All  the  preceding 
symptoms  returned,  she  refused  to  eat,  became  morose,  and  complained  of  severe 


Fig.  30. — Method  of  forcing  the  mouth  open  for  the  purpose  of  forced  feeding.     Long  flexible 
probe  being  passed  between  the  teeth  and  cheek  to  the  last  molar  tooth.      (See  Fig.  31.) 


headache  once  more.  Her  pulse,  blood  pressure,  and  temperature  remained  about 
normal  throughout  all  the  attacks.  That  night  she  slept  well,  having  been 
given  10  grains  of  aspirin  and  1  grain  of  codeine. 

Next  day  the  patient  was  again  docile,  ate  her  breakfast,  and  no  outbreaks 
occurred.  Later  in  the  day,  she  was  put  in  a  chair  without  restraint  and  during 
the  four  succeeding  days,  she  remained  quiet,  but  the  condition  of  her  mind  did 
not  improve.  An  alienist  pronounced  it  delusional  insanity,  and  on  the  twenty- 
first  day  she  was  sent  to  a  private  asylum. 

Most  thorough  eliminative  measures  must  be  attempted  in  these 
cases,  all  the  water  and  alkalies  the  patient  can  tolerate  being  given 
by  mouth,  in  the  rectum,  and  under  the  skin.  Large  amounts  of  salt 
solution  or  plain  distilled  sterile  water  given  subcutaneously  will  often 


224 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


relieve  the  symptoms  and  give  the  patient  rest  and  sleep.  It  may 
become  necessary  for  want  of  attendants  to  restrain  the  patient, 
which  should  he  done  only  when  absolutely  necessary,  the  instruments 
used  being  so  made  that  he  can  not  injure  himself.  Food  must  be 
regularly  given  with  sufficient  alkalies  to  keep  down  an  acid  intoxi- 
cation. Difficulty  in  feeding  these  patients  may  be  so  great  that  the 
stomach  tube  (Figs.  30,  31  and  32),  must  be  resorted  to.  As  to  the 
drugs  which  may  be  necessary,   bromides  are  very  depressing  and 


Fig.  31. — Showing  the  probe  passing  behind  the  last  molar  tooth  ami  tickling  the  fauces. 
thereby  causing  immediate  opening  of  the  mouth.  A  soft  pine  stick  containing  a  round  hole 
is  immediately  placed  between  the  teeth  as  shown  in   Fig.   32. 


should  be  avoided.  Opium  and  hyoscine  particularly  may  he  em- 
ployed. We  have  had  little  occasion  to  use  either  when  the  water 
and  alkali  treatment  is  persisted  in.  The  alkalies  are  given  until 
the  urine  becomes  neutral  or  alkaline.  When  such  measures  do  not 
correct  the  malady  an  alienist  should  lie  culled  and  the  further  treat- 
ment directed  by  him. 

The  patient  should  not  remain  long  in  a  general  hospital.     As  soon 
as  the  surgical  convalescence  has  been  completed,  he  ought  to  be 


POSTOPERATIVE    PSYCHOSES 


22* 


moved  to  a  private  sanitarium  or  to  his  home  as  thought  best  by  the 
medical  man  in  charge.  Hygienic  measures  are  particularly  impor- 
tant, sunshine  and  fresh  air  with  clean  beds,  frequent  warm  baths, 
and  other  measures  necessary  to  prevent  bed  sores,  are  indispensa- 
ble. 

The  surgeon  should  keep  accurate  records  of  such  cases  and  have 
ample  testimony  as  to  what  condition  the  patient  was  in  before  and 
after  the  treatment.  Where  the  patient  suffers  from  a  delusion  of 
persecution,  some  of  these  imaginable  wrongs  may  so  impress  her 
during  the  saner  moments  as  to  acquire  forensic  importance  and  be 


Fig.    32. — Showing  round   soft  pine  stick  tied   in  position   between  the  teeth.      The   round 

hole  in  the  center  of  the   stick  receives  the  feeding  tube.     The  patient  is   thereby  prevented 

from  injuring  himself  and  compressing  the  feeding  tube,  and  consequently  can  not  further 
resist  the  proffered  food. 

the  subject  of  serious  legal  inquiries.  While  every  effort  is  put  forth 
to  help  the  patient,  the  surgeon  must  at  the  same  time  make  ample 
provision  to  protect  himself. 


Febrile  Delirium 

Among  the  other  conditions  which  may  be  confused  with  insanity  is 
febrile  delirium.  This  term  has  arisen  because  of  the  fact  that  most 
of  the  general  diseases  which  cause  delirium  are  febrile.  Delirium  in 
itself  denotes  a  state  of  mental  excitement,  which  comes  on  suddenly, 
is  only  temporary,  and  is  due  to  a  recognizable  cause.     The  mental 


226  AFTER-TREATMENT   OF   SURGICAL   PATIENTS 

manifestation  differs  in  no  essential  way  from  some  of  the  acute  in- 
sanities, but  it  has  become  customary  to  restrict  the  application  of 
this  term  to  certain  intoxications,  to  great  exhaustion,  or  to  emotional 
instability,  as  in  hysteria,  etc.,  to  organic  disease  of  the  brain  or  to 
infections. 

Very  high  temperatures  frequently  cause  delirium,  as  do  also  dis- 
turbances of  the  cerebral  circulation,  but  the  effect  of  the  toxic  sub- 
stances in  the  blood  is  found  to  be  the  cause  in  the  majority  of  these 
instances.  Delirium  does  not  always  follow  a  high  temperature,  this 
condition  being  seen  at  times  in  patients  with  very  little  elevation  of 
temperature,  as  is  the  case  in  children  or  in  old  people. 

According  to  Da  Costa,  delirium  in  septic  cases  usually  makes  its 
first  appearance  in  the  evening  when  the  patient  is  between  waking 
and  sleeping.  It  is  apt  to  clear  upon  becoming  wide  awake  only  to 
reappear  when  the  patient  becomes  drowsy  again.  After  disturb- 
ing the  patient  throughout  the  night,  it  will  clear  up  towards  morning 
only  to  manifest  itself  later  on  during  the  day.  Acute  mania  does 
not  clear  up  as  does  delirium,  and  there  is  no  true  lucid  interval  in 
the  former  condition.  The  onset  is  not  so  rapid  in  mania  nor  is  the 
degree  of  illness  so  intense. 

In  confusional  insanity,  the  same  symptoms  may  be  seen  as  in  de- 
lirium, and  these  conditions  are  easily  confused.  However,  febrile 
delirium  occurs  during  the  febrile  malady  rather  than  following  it 
as  is  seen  in  actual  insanity.  The  treatment  is  the  same  as  for  post- 
operative psychoses. 

Delirium  Nervosum 

Delirium  nervosum  is  a  term  which  lias  been  used  to  describe  a  con- 
dition occurring  within  the  five  or  six  days  following  an  operation, 
in  very  nervous  people.  This  condition  may  follow  injury,  and  hence 
it  is  designated,  by  some,  traumatic  delirium.  Usually  there  is  ma- 
niacal excitement  though  in  some  of  the  patients,  melancholy  depres- 
sion, confusion,  or  even  revelry  with  subsequent  stupor,  are  the 
most  prominent  symptoms.  The  mental  excitement  seen  in  true  delir- 
ium nervosum  has  a  sudden  onset.  The  condition  lasts  several  days 
and  ends  just  as  suddenly  as  it  came.  In  such  a  malady,  hallucina- 
tions, illusions  and  delusions  occurs.  The  condition  is  apt  to  be  con- 
fused with  confusional  insanity,  and,  in  fact,  the  form  with  confusion 
and  a  tendency  to  stupor  is  really  an  insanity.  However,  a  diagnosis 
of  delirium  nervosum  is  not  made  until  it  is  certain  that  the  condition 
is  produced  by  sepsis,  acidosis,  uremia,  etc.  The  patients  usually  re- 
cover if  it  is  purely  a  nervous  phenomena,  though  at  times  a  patient 
dies  in  what  is  diagnosed  as  this  condition. 


POSTOPERATIVE   PSYCHOSES  227 

Senile  Delirium 

Old  people  do  not  stand  operations  well.  Many  of  them  sleep  badly 
and  are  apt  to  be  irritable,  restless,  excitable,  quarrelsome,  and  even 
suspicious.  In  such  a  state  of  mind  and  subjected  to  the  dangers  of  an 
operation  the  aged  are  predisposed  to  delirium.  No  sign  of  mental 
deterioration  may  have  been  noticed  before  the  operation,  though 
soon  afterward  grave  signs  of  this  complication  may  develop,  and 
mania,  melancholia  or  delusions  arise,  which  unfortunately,  may  be 
the  precursors  of  senile  insanity. 

It  is  common  for  such  individuals  to  develop  delirium  during  the 
night,  but  the  daytime  is  not  always  free  from  the  malady.  An  ele- 
vated temperature  may  occur  or  may  not  depending  largely  upon  the 
condition  for  which  he  was  operated.  When  he  wakens  after  the  anes- 
thesia, or  perhaps  hours  later,  the  patient  becomes  irritable,  suspi- 
cious, restless,  inattentive  to  his  surroundings,  and  soon  passes  into 
a  state  of  delirium.  He  talks  and  shouts,  tries  to  get  out  of  bed,  and 
if  at  any  time  he  does  succeed3  wanders  off.  Frequently  there  are 
hallucinations  of  hearing,  and  in  his  excitement  from  these  or  other 
hallucinations,  suicide  may  be  attempted.  He  may  become  erotic,  and 
commonly  he  urinates  or  defecates  in  the  bed.  Such  delirious  con- 
ditions soon  pass  away  unless  a  part  of  true  senile  dementia. 

Hysterical  Delirium 

Hysterical  delirium  is  seen  in  young  women  at  times  after  an  op- 
eration. It  is  most  common  at  the  menstrual  period.  The  condition 
is  precipitated  by  fright,  overstrain,  worry  or  any  violent  excitement. 
It  begins  suddenly,  being  preceded  by  convulsions  or  these  may  not 
occur  at  all.  The  patient  becomes  extremely  excited,  is  very  restless, 
talks  loudly  but  not  incoherently,  and  becomes  very  obstinate.  She 
will  probably  cry,  scream,  lament,  implore,  and  do  anything  to  at- 
tract attention  and  pity.  She  is  perverse  and  is  apt  to  make  indecent 
exposure  or  use  obscene  and  profane  words.  It  seems  that  the  ex- 
citement comes  in  waves  and  during  a  lull,  the  patient  may  suddenly 
ask  intelligent  questions  or  act  normally.  The  whole  condition  is  one 
of  unreality  and  strikes  one  that  the  patient  is  pretending  to  be  out 
of  relation  with  her  surroundings.  The  excitement  usually  ends  after 
an  hour  or  possibly  after  several  hours,  following  which  there  may  be 
lacrimation.  In  such  patients,  the  visual  fields  should  be  examined 
and  the  areas  of  anesthesia  which  are  commonly  found  in  hysteria, 
sought  for. 


228 


AFTER-TREATMENT    OF    SURGICAL   PATIENTS 


Fig.  33.— A  simple  scheme  for  restraining  hands  and   feet  only. 


POSTOPERATIVE   PSYCHOSES 


229 


Other  conditions  which  cause  delirium  and  which  simulate  insan- 
ity can  not  be  too  thoroughly  studied.  Delirium  following  drug 
poisoning,  delirium  of  starvation  (as  in  cancer  of  the  stomach  or 
esophagus).,  of  collapse,  of  fatigue  or  of  delirium  following  acidosis, 
uremia  or  diabetes  must  not  be  confounded  with  insanity.  It  would 
prove  a  serious  mistake  to  call  such  conditions  as  have  been  named, 
beginning  insanity  or  to  state  that  some  organic  brain  disease  is 
causing  the  mental  excitement  when  some  minor  factor,  at  times 
easily  diagnosed,  is  the  sole  cause.  On  the  other  hand,  it  is  a  serious 
blunder  not  to  recognize  those  who  are  actually  insane  and  not  to 
have  them  cared  for  in  a  proper  way. 


Fig.  34.— Showing  the  method  of  restraining  the  body  by  means  of  a  sheet,  the  end  of  which 
is  tightly  pulled  under  the  bed  railing  and  rolled  around  it  as  depicted  in  the  insert. 


The  treatment  should  carry  with  it  every  method  which  will  aid 
efficiently  in  preventing  the  patient  from  injuring  himself.  Eestraint 
(Figs.  33'  to  36)  is  used  only  when  absolutely  unavoidable.  \Ye  have 
found  it  a  good  rule  to  give,  in  such  cases  as  in  the  real  insanities, 
a  large  dose  of  water  and  an  alkali.  A  subcutaneous  injection  of 
2400  c.c.  of  water  at  one  time  will  aid  materially  in  quieting  a  de- 
lirious patient.  Sodium  bicarbonate  and  sodium  citrate  should  be 
given  by  mouth  and  per  rectum.  These  should  be  kept  up  until  the 
urine  becomes  alkaline.     The  former  drug  is  given  60  grains  every 


230 


AFTER-TREATMEXT    OF    SURGICAL   PATIEXTS 


four  hours  while  the  latter  drug  is  usually  administered  in  20  or 
25-grain  doses  in  same  length  of  time. 

Ice  is  applied  to  the  head  and  warmth  to  the  feet,    The  bladder  and 
bowels  are  kept  free  and  diaphoresis  is  encouraged. 


pig.  35. — An  admirable  straight  jacket  with  comfortable  band  arrangement   for  walking  insane 
patients,    Minnesota    State    Hospital,    Rochester. 


Fig.  36. — The  straight  jacket  as  shown  in  Fig.  35  combined  with  a  confining  sheet,  making 
an  absolute  restraint  for  uncontrollable  patients.  The  three  straps  over  this  sheet  may  be 
of  canvas  or  leather. 


Dr.  Stuarl    McGkure  gives  the  following  instructions  to  patients 
suffering  from  postoperative  neurasthenia  when  they  are  discharged 

from  the  hospital. 


POSTOPERATIVE   PSYCHOSES  231 

Your  -wound  has  healed  and  requires  no  further  attention. 

The  operation  has  removed  the  cause  of  your  trouble,  but  it  will  take  some 
time  for  you  to  get  well. 

When  you  get  home  you  should  put  yourself  under  the  care  of  your  physician. 
He  knows  all  that  was  done  for  you  and  all  that  was  learned  about  you  while 
you  were  in  the  hospital. 

Don't  continually  think  about  yourself  and  ask  yourself  how  you  feel.  You 
don 't  know  enough  to  tell  whether  a  symptom  has  any  significance  or  not.  You 
employ  a  doctor.     Let  him  do  the  worrying  for  you. 

Don't  worry  yourself.  Worry  is  thinking  to  no  end.  "Distracted"  means 
drawn  two  ways.  Worry  and  distraction  prevent  rest  and  sleep  and  result  in 
chronic  tiredness. 

The  cure  for  worry  is  concentration  on  something  with  an  end  in  view.  To  be 
wholesome  that  something  must  be  productive.  In  other  words,  you  need  occu- 
pation. 

While  at  the  hospital  you  had  a  "rest  cure."  You  now  need  a  "work  cure." 
Try  to  find  some  light,  useful  work  that  will  occupy  and  interest  you. 

At  meal  times  put  aside  care.  Don't  be  afraid  to  trust  your  digestion.  Don't 
abuse  it,  but  use  your  stomach  confidently. 

Keep  the  bowels  open  by  natural  means  such  as  a  proper  diet,  an  abundance 
of  drinking  water,  a  reasonable  amount  of  exercise  and  a  habit  of  going  to  stool 
at  a  regular  time.     Mild  laxatives  may  be  necessary  occasionally. 

Avoid  stimulants  and  hypnotics  unless  prescribed  by  your  physician. 

On  getting  up  in  the  morning  take  a  cold  sponge  bath.  On  going  to  bed  take 
a  warm  tub  bath.     Sleep  with  the  windows  open. 

Rest  in  a  quiet  room  for  one  or  two  hours  in  the  afternoon. 

Spend  as  much  time  in  the  fresh  air  and  sunshine  as  your  strength  and  the 
weather  will  permit. 

Increase  exercise  as  you  gain  strength,  stopping  when  you  get  tired  and  not 
going  until  you  get  exhausted. 

Please  report  your  condition  by  mail  at  the  end  of  three  months.  If  you  are 
doing  well  the  information  will  help  us,  if  you  are  not  doing  well  we  may  be  able 
to  help  you. 

Bibliography 

^Kelly:     Surg.,  Gynec,  and  Obst.,  1909,  ix,  519. 

2Da  Costa:     Surg.,  Gynec  and  Obst.,  1910,  xi,  577. 

sSelberg:  Beitr.  z.  klin.  Chir.,  1904,  xliv,  173. 

4Grekow:     Annal  de  Russe  chir.,  1901,  i. 

sPicque:     Bull,  et  mem.  Soc  de  chir.  de  Paris,  xxiv,  171. 

sUrbaeh:      Wien.  klin.  Wchnschr.,  xlvii,   1465. 

^Stoner:     Iowa  Med.  Jour.,  1912,  xviii,  247. 

sBerkley:     Mental  Diseases,  1900. 

sKaller:     Archiv.  f.  Psyehiat.,  xxvii,  286. 
iQMacPhail:     Brit.  Med.  Jour.,  September,  1899. 
nWerth:     Zentralbl.  f.  Gynak.,  xxiv,  387. 
i2Fillebrown :     Am.  Jour.  Obst.,  1889,  xxii,  32. 
isMumford:     Boston  Med.  and  Surg.  Jour.,  1910,  elxiii,  S41. 
wAikin:     Am.  Jour.  Med.  St.,  1915,  cxlix,  715. 
The  following  was  also  consulted: 

Rayneau:     Congres  des  Med.  Alien  et  Xeur.  Angers,  1S9S. 


CHAPTER  XXVIII 

ACID  INTOXICATION 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Acetoimria  is  of  such  frequent  occurrence  in  postoperative  conva- 
lescence that  it  is  incumbent  upon  me  to  give  it  extended  mention. 

Its  importance  is  manifested  by  a  symptom-complex  of  greater  or 
lesser  severity,  depending  upon  the  amount  of  retained  acids  in  the 
body,  which  condition,  for  want  of  a  better  name,  has  been  termed 
"acidosis."  The  degree  of  this  de-alkalinization  of  the  body  fluids  or 
acid  intoxication  may  become  so  great  as  not  only  to  cause  most  se- 
vere symptoms,  but  even  death,  in  fact  this  one  complication  alone 
is  claiming  its  victims  by  the  thousand. 

General  anesthetics  came  into  use  about  the  middle  of  the  nine- 
teenth century,  and  while  from  the  start  success  attended  their  use, 
there  soon  was  noticed  a  factor  which  up  to  this  time  had  never  been 
called  to  the  attention  of  the  experimenters  in  this  field.  This  new 
factor  appeared  two  to  three  days  after  the  narcosis  in  the  form  of 
a  profound  intoxication,  at  times  accompanied  with  incessant  vomit- 
ing. As  anesthesia  became  more  genera]  just  so  did  this  new  con- 
dition increase  in  prominence  and  severity.  An  explanation  was  not 
forthcoming,  and  since  these  toxic  patients  frequently  died  in  coma, 
the  condition  was  thought  to  be  diabetes.  As  fate  would  have  it,  the 
tii'st  discovery  of  acetone  was  made  in  a  diabetic  patient.  After  this 
discovery  by  Peters1  in  1857,  it  was  repeatedly  demonstrated  by  him 
in  other  severe  cases  of  diabetes.  Soon  thereafter  Kaulisch2  found  it 
present  in  varying  quantities  in  all  stages  of  this  disease,  and  first 
described  the  symptoms  of  acidosis  which  was  then  termed  aceto- 
nemia. Kussmaul3  in  1874  in  describing  diabetic  coma  mentioned  the 
likely  importance  of  the  toxic  action  of  acetone  as  a  causative  factor. 
During  this  time  chloroform  was  the  popular  anesthetic,  and  many 
deaths  occurred  in  which  the  symptoms  of  acid  intoxication  were 
noted,  but  the  deaths  were  attributed  to  other  causes.  Such  cases 
were  reported  by  Casper,  Konig,  Volkmann  and  others.  Kast  and 
Mester4  in  1891  studied  the  urine  in  these  cases  and  found  among 
other  things  hyperacidity.  In  1894,  Becker5  working  along  the  same 
lines  but  in  addition  examined  for  acetone  tin1  urines  of  about  fif- 
teen  hundred   healthy   individuals   before    and    after   operation    and 

232 


ACID    INTOXICATION  233 

found  a  pathologic  amount  in  over  60  per  cent  of  the  cases  following 
narcosis ;  three  fatal  cases  being  reported  by  him.  During  this  same 
year  Guthrie7  reported  nine,  more  fatalities.  A  year  later  Stocker6 
added  another  case  to  the  list.  Other  cases  were  reported  from  time 
to  time,  but  in  each  one  chloroform  was  given  as  the  cause  of  death. 

Brewer55  in  1902  first  reported  a  fatal  case  which  without  a  doubt 
was  due  purely  to  acid  intoxication,  in  a  patient  free  of  diabetes. 
Two  years  later  Bracket,  Stone,  and  Lowt1°  cited  several  instances  of 
acid  intoxication  in  nondiabetic  patients  and  gave  an  exhaustive 
study  of  the  whole  subject.  After  this  work  operators  seriously  con- 
sidered this  possibility  and  henceforth  acidosis  assumed  clinical  im- 
portance. Bevan  and  Favill11  in  1905  reported  one  case  and  collected 
28  more  of  acid  intoxication  following  chloroform  narcosis.  One 
year  later  Beesly12  reported  17  cases  in  which  he  mentioned  acute 
and  chronic  acidosis.  Later  on  Campbell13  and  McArthur14  each 
reported  fatal  acid  intoxication  following  chloroform  anesthesia.  In 
1908  Eice15  found  an  excess  of  acetone  in  the  urine  following  ether 
narcosis  in  90  per  cent  of  202  patients  who  were  not  diabetics.  Of 
214  cases  reported  by  Bradner  and  Keimann16  in  1915  a  pathologic 
amount  of  acetone  was  found  in  61.7  per  cent  of  them  following 
ether.  In  17  per  cent  diacetie  acid  was  present,  but  always  in  asso- 
ciation with  large  amounts  of  acetone. 

It  has  long  been  known  that  acetone  occurs  in  minute  quantities 
in  the  urine  and  blood  of  normal  individuals.  This  materially  in- 
creases in  amount  in  fevers,  wasting  diseases,  insufficient  carbohy- 
drate diet,  and  particularly  following  anesthesia.  The  amount  of  the 
anesthetic,  the  length  of  time  given,  and  the  kind  of  operation  ap- 
parently have  no  bearing  on  the  extent  of  the  intoxication.  It  ap- 
pears after  local  anesthesia  in  a  high  percentage  of  cases  as  Gell- 
horn17  has  recently  shown.  It  occurs  more  often  in  women  than  in 
men,  and  is  as  frequent,  in  the  infective  diseases  in  children,  as  is 
fever  itself.18 

The  formation  of  the  acetone  bodies  (betaoxybutyric  acid,  diacetie 
acid,  and  acetone)  is  due  chiefly  to  fat  metabolism,  with  the  forma- 
tion of  free  fatty  acids,  and  is  largely  dependent  on  a  reduction  of 
the  carbohydrate  and  protein  diet,  also  in  general  subnutrition.10 
Where  acetbnuria  is  found  clinically,  there  is  often  an  intestinal  dis- 
turbance which  results  in  a  defective  nutrition  of  the  body,  associated 
with  waste  of  the  adipose  body  tissue.19  It  follows,  then,  that  the 
fat  which  breaks  down  may  be  the  food  fat  or  as  is  usually  the  case, 
the  body  fat,    But  at  any  rate  the  immediate  cause  of  the  appearance 


234  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

of  a  pathologic  amount  of  these  bodies  is  the  disturbance  of  the  metab- 
olism. 

Experimentally  acetone  is  readily  formed  from  fat  or  carbohy- 
drates. Blumenthal  and  Neuberg20  produced  acetone  from  gelatin 
and  it  is  probable  that  it  may  be  obtained  from  protein. 

The  first  observers  thought  acetone  might  occur  from  breaking 
down  of  the  proteins,  but  this  was  discouraged  by  von  Noorden,  Ho- 
nigmann  and  others.  Recently,  however,  the  question  has  again  been 
raised  by  Chapin  and  Pease-1  who  have  demonstrated  an  acidosis  in 
children  from  feeding  a  protein  diet   in   gastrointestinal  diseases. 

Just  why  acid  intoxication  develops  is  a  question  which  has  not 
been  definitely  decided.  An  acetonuria  does  not  denote  an  acidosis 
though  it  may  be  the  forerunner  of  an  acid  intoxication.  This  phase 
of  the  condition  has  been  studied  by  von  Jacksch,22  Baginsky,23  Lo- 
renz24  and  many  others.  Baginsky  in  1888,  showed  that  the  severity 
of  the  symptoms  were  dependent  upon  the  height  of  the  fever  and  the 
kind  of  food  allowed.  He  considered  it  a  disturbance  of  metabolism. 
Lorenz  in  1890,  while  agreeing  with  Baginsky,  thought  that  gastro- 
intestinal disturbances  were  the  primary  factors  in  creating  this  un- 
natural condition.  Chapin  and  Pease.21  hold  that  through  such  dis- 
turbances the  epithelium  of  the  intestinal  tract  is  so  damaged  by  the 
acids  or  bacterial  products  thus  produced  that  the  toxins  penetrate 
the  membrane.  Under  such  conditions  the  salts  of  the  food  may  pass 
into  the  blood  in  such  concentration  as  to  act  as  poison  to  the  body 
cells.  Water  is  consequently  withdrawn,  and  this  produces  the  thirst 
so  commonly  observed  in  acidosis.  These  abnormal  acids  demand  an 
increase  of  alkalies,  which  necessarily  causes  a  diminution  of  them 
in  the  blood.  With  the  lowering  of  the  alkalinity  of  the  blood  the 
body  cells  are  damaged  and  the  nitrogen  output  is  thereby  increased. 
Extensive  withdrawal  of  the  alkalies  and  water  may  permanently 
damage  the  body  cells  with  the  result  that  loss  of  weight,  and  in  in- 
fants, malnutrition  and  even  atrophy  occur  after  an  acid  intoxica- 
tion. 

Howland  and  Marriott2"1  have  tried  to  find  an  explanation  for  acid- 
osis in  the  retention  by  the  kidneys  of  acids  which  are  the  product 
of  metabolism.  In  support  of  this  view  they  call  attention  to  the 
lessened  urinary  output  and  suggesl  that  this  may  be  due  to  the  loss 
of  the  acid  excretory  function.  As  has  long  been  known  there  is  an 
increase  in  the  watery  content  of  the  stool,  during  diminution  of  the 
urinary  secretion.  Experimentation  is  now  being  carried  on  to  prove 
this  theory,  but  while  we  await  the  result  we  are  as  far  away  from 
a  solution  of  this  problem  as  were  those  men  of  a  half  century  ago. 


ACID   INTOXICATION  235 

It  must  be  remembered  that  the  body  is  constantly  elaborating 
acids  as  the  result  of  oxidative  processes  in  intermediary  metabolism 
and  in  order  to  neutralize  these  acids  there  is  maintained  a  certain 
alkali  reserve  in  the  blood.  It  is  derived  from  the  sodium  bicarbonate 
in  the  plasma  and  in  the  corpuscles.  The  acid  and  alkaline  phos- 
phates of  sodium  and  potassium  are  found  in  the  red  cells,  and  the 
proteins.  These  constitute  the  defenses  of  the  animal  organism.  In 
addition  there  is  a  further  defense  in  that  ammonia  can  be  produced 
and  utilized  to  neutralize  acids  when  these  appear  in  excessive 
amounts ;  the  whole  being  under  the  control  of  a  central  nervous 
mechanism. 

Anything  which  tends  to  break  down  these  body  defenses  predis- 
poses to  acidosis.  Lorenz  long  ago  showed  that  fright  or  hyperex- 
citability  was  indeed  a  fruitful  cause  of  this  condition.  Bracket, 
Stone  and  Low,  also  found  that  homesickness,  nervousness  from  too 
long  confinement  in  the  hospital  or  the  excitement  of  seeing  other  pa- 
tients recover  from  the  intoxication  of  an  anesthesia,  was  a  predispos- 
ing cause.  Other  causes  outside  those  already  mentioned  are  chronic 
diseases  of  the  liver,  exhaustion  from  hemorrhage,  starvation,  fatty  de- 
generation of  the  muscles,  as  may  occur  in  paralyzed  limbs,  and  a 
lowered  general  vitality  as  in  sepsis,  or  diabetes. 

As  a  rule  the  symptoms  of  acid  intoxication  following  operation 
appear  in  from  one-half  day  to  six  days,  though  the  elimination  of 
acid  bodies,  however,  ceases  within  three  days.  As  was  shown  by  Wil- 
ber26  in  1904  and  again  recently  by  Marriott,  the  severity  of  the 
symptoms  is  not  dependent  upon  the  amount  of  the  acetone  bodies 
present  and  a  most  severe  intoxication  may  be  seen  without  any  ma- 
terial increase  in  these  bodies.  Keller27  and  others  have  sought  in 
vain  to  find  other  abnormal  acids  which  would  account  for  the  symp- 
toms. In  view  of  the  above  facts  one  should  not  overlook  these  cases 
of  intoxication  because  merely  a  slight  trace  of  acetone  is  found  in 
the  urine  and  because  the  acetone  bodies  in  the  blood  have  not  in- 
creased at  all. 

The  patient  usually  complains  of  being  sick,  "so  sick  all  over" 
and  begins  to  vomit  a  day  or  so  following  the  operation  or  the  nau- 
sea and  vomiting  from  the  anesthetic  may  not  as  yet  have  ceased. 
He  is  irritable  and  restless.  The  appetite  has  not  reappeared  and  the 
breath  has  a  sweetish  fruity  odor.  The  symptoms  may  be  mild  and 
pass  away  in  a  few  hours.  In  very  severe  cases  the  patient  not  alone 
complains  of  being  sick  "enough  to  die,"  but  looks  it.  The  face  be- 
comes ashen  gray,  the  lips  pale  and  dry,  the  eyes  sunken  and  glassy. 
The  skin  is  moist  and  cold  or  in  some  cases  is  hot  and  dry  and  the  pa- 


236  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

tieut  may  become  jaundiced.  A  temperature  from  100  to  103  is 
likely  to  be  present  with  a  rapid  weak  pulse.  During  this  state  of 
collapse  delirium  may  be  noted,  even  followed  by  convulsions  be- 
tween the  paroxysms  of  vomiting.  Usually  apathy  and  stupor  will 
be  noted  later.  This  quiet  does  not  last  long  and  the  patient  again 
becomes  restless  and  active  in  his  delirious  state.  As  the  condition 
increases  in  severity,  the  victim  passes  into  a  stupor  which  deepens 
into  coma.  The  respiration  becomes  difficult  and  finally  takes  on  the 
Cheyne-Stokes  type,  the  heart  weakens,  and  the  patient  dies  without 
regaining  consciousness. 

Many  observers  have  described  a  type  of  acid  intoxication  which 
comes  about  four  days  after  operation,  appearing  suddenly  in  pa- 
rents, particularly  children,  in  whom  the  convalescence  had  given 
no  reason  for  alarm.  The  sick  one  suddenly  becomes  irrational, 
wildly  excited,  and  uncontrollable.  Under  powerful  medication  he 
may  quiet  down,  only  to  start  up  again  with  a  piercing  shriek  fol- 
lowed by  agonizing  moans,  he  soon  develops  the  symptoms  noted 
above  and  frequently  is  dead  in  thirty-six  hours. 

Space  does  not  permit  ;i  description  of  the  various  tests  for  acetone. 
Sellards28  by  removing  the  proteins  from  the  blood  serum  with  abso- 
lute alcohol  titrated  the  filtrate  with  phenolphthalein.  Under  normal 
conditions  a  deep  purple  is  seen,  but  if  acidosis  is  present,  the  color 
is  much  lighter  or  even  absent.  Howland  and  .Marriott  have  de- 
scribed a  very  accurate  method  of  diagnosing  acidosis,  particularly 
in  children,  by  determinating  the  carbon  dioxide  tension  of  the  air  in 
the  alveoli  of  the  lungs.  An  increased  acidity  of  the  blood  stimu- 
lates the  respiratory  center  to  increased  activity  in  order  to  reduce 
the  carbon  dioxide,  so  that  the  hydrogen-ion  concentration  may  be 
kept  at  a  normal  level.  The  carbon  dioxide  tension  in  the  alveolar  air 
will  be  the  same  as  the  carbon  dioxide  tension  in  the  blood.  Van 
Slyke  more  recently  has  elaborated  a  method  by  which  the  carbon 
dioxide  tension  of  the  blood  may  be  determined.  These  methods  are 
the  most   accurate  we  have  of  determining  an  early  acidosis. 

A  simple  method  of  determining  acetone  in  urine  is  that  described 
by  Lange.29  "About  15  c.c.  of  urine  are  placed  into  a  test  tube  and 
treated  with  1  c.c.  glacial  acetic  acid.  To  this  add  a  knifepoint  of 
ground  sodium  nitroprusside,  dissolve  by  turning  the  test  tube  up 
several  times.  Now  overlay  with  strong  ammonium  hydrate.  In  the 
presence  of  acetone  an  intense  violet  ring  appears  at  the  line  of  con- 
tact.    The  test  will  show  acetone  in  %00  Per  cen1  solution." 

"Diacetic  acid  is  tested  for  by  adding  an  excess  of  10  per  cent  ferric 
chloride  to  about  20  c.c.  of  urine  in  a   test  tube.     The  precipitate 


ACID   INTOXICATION  237 

which  forms  is  removed  by  filtration.  To  the  filtrate  add  more  of 
the  chloride.  A  deep  Bordeaux  red  color  will  appear  in  the  presence 
of  diacetic  acid.  The  contents  of  the  test  tube  are  now  halved  and 
one  portion  boiled,  and  compared  to  the  one  unboiled.  The  color 
lessens  due  to  the  breaking  up  of  the  diacetic  acid.  The  test  in- 
dicates .04  to  .05  per  cent  of  diacetic  acid."30 

To  anticipate  this  mystifying  disorder  it  is  very  important  to  in- 
stitute measures  of  prevention.  Such  measures  were  carried  out  with 
some  degree  of  success  by  Wallace  and  Gillepsie.31  Their  example 
was  soon  followed  by  Brown.3-  Since  then  many  men  have  been  ac- 
tive along  this  line,  notable  among  them  being  Chile,33  with  his  well- 
known  "  anoci-association. "  Recently  Quillian34  has  reported  the  re- 
duction of  the  occurrences  of  acidosis  by  carrying  out  a  routine  pre- 
operative treatment.  I  have  for  some  time  given  my  patients  so- 
dium bicarbonate  one-half  ounce  in  water  three  times  a  day  half  an 
hour  before  meals  for  two  days  preceding  operation.  Glucose  is  given 
per  mouth  as  much  as  the  patient  will  take  and  a  glassful  of  water 
every  hour  or  so  up  until  within  an  hour  of  the  operation.  In  addi- 
tion every  effort  is  made  to  assure  the  patient  and  get  him  accus- 
tomed to  the  surroundings.  His  habits  and  mode  of  living  are  dis- 
arranged as  little  as  possible  and  nothing  is  allowed  to  occur  which 
would  in  any  way  cause  excitement,  or  concern.  The  nights  are 
spent  in  quiet,  bromides  being  given  to  insure  quiet  if  necessary. 

In  spite  of  every  preventive  measure,  acetone  may  appear  as  in 
fact  it  does  in  the  great  majority  of  patients.  Following  the  anes- 
thetic then  in  such  cases  water  is  started  by  mouth  as  soon  as  the 
patient  is  able  to  retain  it,  and  after  a  day  or  so  a  pitcher  is  put  by 
the  bedside  and  the  patient  encouraged  to  drink  a  glassful  every  hour 
or  two.  Continuous  proctoclysis  is  kept  up  for  twenty-four  hours, 
plain  tap  water  containing  glucose  to  the  amount  of  2  per  cent  being 
used.  An  ounce  of  sodium  bicarbonate  is  added  to  each  quart  of 
proctoclysis,  while  sodium  bicarbonate  is  given  per  mouth.  Others 
have  advised  an  enema  containing  one  ounce  of  olive  oil  and  one 
ounce  of  glucose  in  one  pint  of  tap  water,  two  hours  before  operation, 
the  whole  to  be  retained  throughout  the  operative  procedure.  In 
cases  where  a  violent  condition  demands  more  alkali nization,  a  2 
per  cent  solution  of  sodium  bicarbonate  in  plain  sterile  distilled 
water  is  given  in  a  continuous  subcutaneous  injection.  Marriott 
would  give  intravenously  a  4  per  cent  solution.  Five  per  cent  glu- 
cose may  be  given  under  the  skin  in  the  same  solution  with  the  al- 
kali. Morphine  pushed  to  the  physiologic  effect  has  almost  a  specific 
action.     Carbohydrate  feeding  must  constitute  our  sheet  anchor  and 


238  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

will  be  referred  to  more  in  detail  in  the  chapters  on  feeding,  etc. 
The  time-honored  custom  of  giving  postoperative  patients  proteins  in 
the  form  of  broths,  with  no  thought  of  their  physiologic  needs,  has 
become  so  thoroughly  ingrained  in  many  of  our  hospitals  that  it  will 
die  hard. 

Bibliography 

iPeters:     Quoted  by  Kraus:     Alleg.  Path.  Lubarsch  unci  Ostertag,  Heft  2,  1895. 

-'Kauliseh:     Prag.  Vrtljschr.,  1857,  xiv. 

sKussmaul:     Ztschr.  f.  klin.  Med.,  Berlin,  vi. 

*Kast  and  Mester:     Ztsehr.  f.  klin.  Med.,  xviii,  -469. 

sBecker:     Deutsch.  med.  Wehnschr.,  1894,  xviii,  469. 

eStocker:     Zentralbl.  f.  Gynak.,  1895,  No.  45. 

^Guthrie:     Lancet,  London,  1894,  i,  193. 

sBrewer:     Ann.  Surg.,  1902,  ii,  489. 

sKelly:     Ann.  Surg.,  1905,  ii,  161. 
loBracket,  Stone,  and  Low:     Boston  Med.  and  Surg.,  1904,  p.  151. 
nBevan  and  Favill:     Jour.  Am.  Med.  Assn.,  1905,  xlv,  691. 
i-'Beesly:     Brit.  Med.  Jour.,  1906,  ii,  1146. 
JsCampbell:     Med.  Press  and  Circular,  1907,  lxxxiii,  198. 
uMcArthur:     Intercolonial  Med.  Jour.,  Australasia,  1907,  xii,  434. 
isEice:     Boston  Med.  and  Surg.  Jour.,  1908,  clix,  47. 
16Bradner  and  Reimann:     Am.  Jour.  Med.  Sc.  1915,  cl,  727. 
"Gellhom:     Zentralbl.  f.  Gynak,  1914,  xxxviii,  1204. 
isHowland  and  Marriott:     Bull.  Johns  Hopkins  Hosp.,  March,  1916. 
ifWaldvogal :     Centralbl.  f.  inmere  Med.,  July,  1899. 
2"Blumenthal  and  Neuberg:     Deutsch.  med.  Wehnschr.,  xxvii. 
2iChapin  and  Pease:     Jour.  Am.  Med.  Assn.,  November,  1916,  p.  1353. 
--Von  Jacksch:      Ztschr.  f.  klin.  Med.,  viii. 
23Baginsky:     Arch.  f.  Kinderh.,  1888,  ix,  1. 
z-iLorenz:     Ztschr.  f.  klin.  Med.,  1891,  xix. 

25Howland  and  Marriott:     Am.  Jour.  Dis.  Child.,  May,  1916,  309. 
26Wilber:     Jour.  Am.  Med.  Assn.,  October,  1904,  p.  1228. 
2"Keller:     Malzsuppe,  eine  Nahrung  fur  Magendarmkranke  Sanglinge,  189S. 
288ellards:      Bull.  Johns  Hopkins  Hosp.,  1914,  xxv,  147. 
zsLange:     Miinchen  Med.  Wehnschr..  1906.  liii,  1764. 

soMorris:     Clinical  Laboratory  Methods,  1913,  New  York,  D.  Appleton  &  Co. 
siWallace  and  Gillepsie:     Practitioner,  February,  1910. 
32Brown:     Brit.  Med.  Jour.,  1911,  i,  428. 
ssCrile:     Ann.  Surg.,  1915,  lxii,  257. 
3-JQuillian:     Ann.  Surg.,  1916,  lxiii,  385. 


CHAPTER  XXIX 

DIABETES  IN  SURGERY 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Glycosuria  is  a  complication  which  is  certainly  not  desirable  in 
any  surgical  convalescence.  Operations  upon  patients  suffering  from 
this  condition  are  usually  not  performed  without  an  attempt  being 
made  to  determine  the  responsible  factors  which  are  bringing  this 
about,  and  without  medical  treatment  being  instituted  to  correct  the 
abnormality.  It  is  frequently  difficult  in  the  presence  of  surgical 
necessities  to  distinguish  between  temporary  or  nondiabetic  glyco- 
suria and  true  diabetes.  In  fact,  as  early  as  1884  Verneuil1  stated  that 
no  one  could  definitely  say  where  glycosuria  ends  and  diabetes  begins. 
The  present  day  surgeons  look  upon  sugar  in  the  urine  as  a  serious 
fact  and  do  not  try  to  differentiate  such  a  finding  from  true  diabetes. 
Instead,  they  have  inclined  to  follow  out  a  classification  which  was 
probably  first  suggested  by  Smith  and  Durham2  which,  though  more 
or  less  modified,  is  about  as  follows :  first,  cases  in  which  glycosuria 
is  caused  by  the  surgical  lesion ;  second,  cases  in  which  the  lesion 
causes  the  surgical  condition;  third,  cases  in  which  the  two  are  in- 
dependent and  do  not  influence  each  other;  fourth,  cases  in  wdiich 
glycosuria  is  a  harmful  factor  and  increases  the  danger  of  the  already 
existing  disease  or  injury. 

Of  the  first  class  of  cases  it  may  be  said  that  glycosuria  is  not  un- 
commonly caused  by  the  surgical  lesion  particularly  in  cases  of  in- 
jury or  sepsis.  Redard3  suggested  that  they  be  classified  as  (1)  in- 
juries of  the  central  nervous  system;  (2)  cellulitis,  lymphangitis, 
and  erysipelas;  (3)  carbuncle;  (4)  gangrene;  (5)  septicemia;  (6) 
injuries  such  as  fractures  and  operations.  To  above  other  operators 
have  added  glycosuria  as  secondary  to  sloughing  new  growths,  and  cer- 
tain other  intraabdominal  and  intrapelvic  diseases.  In  such  cases  the 
amount  of  sugar  ranges  from  .1  to  2.50  per  cent,  is  accompanied  with 
a  more  or  less  albuminuria  and  an  increase  of  the  total  twenty-four 
hour  quantity  of  urine ;  these  urinary  findings  being  only  transitory. 
Other  diabetic  symptoms  such  as  thirst,  itching  skin,  etc.,  were  pres- 
ent in  these  cases.  This  condition  as  a  consequence  of  appendicitis 
has  been  mentioned  by  Da  Costa,4  Leidy,5  Cohn,6  and  others.  In 
some  of  these  cases  the  percentage  of  the  sugar  was  as  high  as  2.5  per 

239 


240  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

cent  and  usually  lasted  as  long  as  there  was  any  evidence  of  the  disease. 
Imlaeh7  reported  a  ease  of  pyosalpinx  in  which  all  the  symptoms  of 
diabetes  appeared  with  the  occurrence  of  the  disease  and  the  patient 
was  cured  only  by  removal  of  the  tubes.  Strangulated  hernias  have 
produced  a  glycosuria.  Neugebauer,s  experimenting  in  an  effort  to 
find  immediate  cause  of  this  complication  in  such  cases,  discovered 
that  ligation  of  the  vessels  of  the  small  intestines  brought  about  gly- 
cosuria. Croom,9  Beyea,10  and  others  have  noticed  this  occurring  in 
patients  having  large  tumors  and  have  attributed  it  in  many  cases 
to  the  increased  intraabdominal  pressure.  In  Beyea 's  case,  the  tumor, 
an  ovarian  cyst,  weighed  58  pounds,  and  7  per  cent  of  sugar  was 
found  in  the  urine.  C41ycosnria  following  gangrene  has  been  noted 
several  times  in  the  literature.  Phillips11  in  1902  reported  a  severe 
case  of  traumatic  gangrene  in  which  the  glucose  reached  nearly  4 
per  cent;  this  completely  disappeared  with  the  removal  of  the  affected 
limb,  which  in  this  instance  was  the  left  arm. 

Recently  Konjetzny  and  Weiland12  have  found  that  in  about  50 
per  cent  of  fracture  cases  there  is  a  spontaneous  or  alimentary  gly- 
cosuria, which  like  the  above  is  only  transitory.  However,  the  symp- 
toms of  diabetes  are  not  noted  despite  the  presence  of  a  hyperglyce- 
mia. The  glycosuria  appears  at  once  or  it  may  not  occur  for  a  few 
days  l»ut  disappears  at  the  end  of  from  fifteen  to  twenty  days.  True 
diabetes  rarely  occurs;  hut,  when  it  does,  more  thai)  six  months  will 
have  elapsed  after  the  injury.  Symptoms  of  this  disease  will  per- 
sist permanently. 

The  actual  cause  of  the  glycosuria  in  these  cases  may  he  an  ana- 
tomic injury  such  as  fat  embolism  or  a  purely  functional  disturbance. 
Frequently  it  is  a  combination  of  both. 

Regarding  the  second  class  of  cases,  "it  is  doubtful  whether  dia- 
betes can  directly  cause  any  surgical  lesion  except  vulvovaginitis, 
balanoposthitis  and  possibly  cataract."  The  gangrene  which  occurs 
in  diabetes,  according  to  Phillips,  is  due  to  the  arteriosclerosis  or  nerve 
degeneration  which  result  from  the  constitutional  disease.  Carbun- 
cle and  other  infections  are  to  be  regarded  in  the  same  Light.  The 
resistance  being  lowered  in  all  diabetics,  such  patients  respond  very 
badly  to  any  injury,  surgical  or  accidental.  The  mortality  from  op- 
eration in  such  cases  is  still  high  in  spite  of  the  fact  that  newer  forms 
of  anesthesia  such  as  nitrous  oxide  and  oxygen,  local  infiltration  and 
even  spinal  analgesia  replace  ether,  while  preoperative  treatment  re- 
duces the  amount  of  sugar.  Seven  patients  with  balanoposthitis  were 
operated  by  French  authors  and  one  died  from  extensive  gangrene, 
while  of  102  operations  for  cataract  Legendre  found  that  99  were 
successes. 


DIABETES    IN    SURGERY  241 

From  a  surgical  standpoint  class  three  is  the  most  important  since 
here  are  placed  the  new  growths,  fractures  and  other  injuries  occur- 
ring independently  in  diabetics,  and  especially  so  since  this  disease 
may  at  the  time  of  the  surgical  emergency  he  unknown,  as  the  symp- 
toms may  be  intermittent.  Phillips  reported  32  per  cent  mortality 
in  operations  on  the  face  and  mouth  for  malignancy  which  occurred 
in  the  presence  of  diabetes.  Of  the  mouth  and  lip  cases  alone  the 
mortality  was  but  25  per  cent. 

In  operations  on  the  breast  there  were  13.4  per  cent  mortality.  On 
the  genital  organs  24  per  cent,  but  in  simple  plastic  operations  the 
mortality  was  nil.  The  bad  results  were  apparently,  due  to  infection 
which  was  of  course  facilitated  by  the  lowered  vitality  of  the  tissues. 

Abdominal  operations  including  hernia,  appendicitis,  colostomy  for 
malignant  disease  in  Phillips  collection  of  cases  showed  a  mortality 
of  26.3  per  cent.  In  operations  upon  the  extremities  the  mortality 
was  about  33  per  cent.  These  cases  included  crush  injuries,  aneurysm 
neoplasm,  and  fractures. 

Fractures  occurring  in  diabetic  patients  are  considered  doubly  se- 
rious since  nonunion  or  delayed  union  is  so  apt  to  occur.  Von  Noor- 
den13  stated  after  a  study  of  the  researches  of  Toralbo,  Van  Ackeren, 
and  Gerhardt,  that  diabetics  often  excrete  an  excess  of  phosphoric 
acid  and  lime  salts  over  the  quantity  derived  from  the  food  ingested, 
and  that  they  must  come  from  the  tissues  of  the  body.  Naturally  this 
can  only  be  from  the  bones,  since  an  administration  of  alkalies  causes 
a  decrease  in  the  excretion  of  lime ;  Gerhardt  thought  this  was  due  to 
increased  acidity.  Of  the  cases  reported  by  Smith  and  Durham  more 
than  50  per  cent  showed  delayed  union  or  nonunion.  Phillips  cites 
other  cases  of  nonunion,  and  while  perfect  union  does  occur,  he  thinks 
the  former  is  more  common.  Von  Noorden  advised  the  giving  of 
calcium  carbonate  to  all  these  patients  with  fracture  in  an  effort  to 
supply  the  deficiency  of  lime.  Such  treatment  carried  out  will  no 
doubt  decrease  the  number  of  delayed  or  nonunions. 

The  fourth  class  of  cases  includes  those  instances  in  which  a  septic 
element  is  already  present  at  the  time  of  the  observation.  It  includes 
therefore  gangrene,  localized  infections,  etc. 

The  question  of  gangrene  is  an  important  as  well  as  an  interesting 
one.  The  so-called  diabetic  gangrene  is  now  considered  simply  a  gan- 
grene occurring  in  a  diabetic  patient.  Such  a  term  is  usually  applied 
to  gangrene  occurring  in  the  lower  extremities.  Considerable  liter- 
ature has  accumulated  on  this  subject,  which  has  been  complicated  by 
the  fact  that  senile  gangrene  is  usually  accompanied  by  glycosuria. 
Gussenbauer,14  who  has  done  extensive  work  along  this  line,  advo- 


242  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

cates  "diet  and  general  palliative  treatment  first  for  this  condition. 
The  arteries  must  be  carefully  watched  on  both  sides  of  the  leg,  and 
if  the  pulse  can  be  felt  distinctly  in  both  the  anterior  and  posterior 
tibial  and  dorsalis  pedis  arteries  local  removal  of  the  diseased  tissue 
will  be  sufficient.  If,  however,  a  pulse  can  be  obtained  in  the  popli- 
teal artery  only  amputation  of  the  leg  below  the  knee  may  be  per- 
formed, provided  the  gangrene  has  not  spread  beyond  the  dorsum 
of  the  foot  and  the  leg  is  free  of  phlebitis  and  lymphangitis.  If  at 
any  time  in  doubt,  amputation  must  be  done  through  the  thigh."  Ac- 
cording to  the  Bartholomew  Hospital  Reports  failure  to  recognize  this 
rule  carries  with  it  a  75  per  cent  mortality. 

Otitis  media  is  common  in  diabetes,  infection  spreading  up  from  the 
pharynx  which  is  often  in  a  state  of  catarrh.  The  onset  is  usually 
sudden  and  the  pain  is  very  severe  and  persists  even  though  there  is 
a  free  discharge  through  the  external  meatus.  The  discharge  is  very 
apt  to  be  bloody  and  according  to  Eulenstein15  there  is  great  tendency 
to  mastoiditis  and  necrosis.  The  disease  may  run  a  normal  course, 
but  in  many  instances  an  extensive  cellulitis  is  present. 

Cellulitis  starting  in  the  bursa  olecrani  which  necessitated  amputa- 
tion of  the  arm  is  reported  by  Spencer,  the  patient  recovering. 
Naunyn  cites  an  instance  of  a  large  thoracic  abscess  which  was  soon 
followed  by  an  abscess  of  the  prostate.  Following  operation  both 
abscesses  healed  without  further  complication.  This  case  bears  out 
Nicholas' 1G  observations  stated  below  that  glucose  favors  the  pyogenic 
properties  of  many  microorganisms,  while  it  diminishes  their  viru- 
lence. 

It  has  been  emphatically  stated  that  the  urine  must  be  examined 
for  sugar  if  after  an  operation  the  wound  for  no  apparent  cause  be- 
comes septic  or  sloughs.  This  is  frequently  found  present  although 
absent  before  the  operation;  it  being  a  case  of  latent  diabetes,  sugar 
reappears  after  the  general  functional  disturbance  caused  by  the 
anesthetic  or  by  the  mental  effects  of  the  operation.  It  is  well  known 
that  sugar  when  originally  present  is  increased  in  diabetics  under 
like  circumstances. 

In  a  septic  process,  which  at  times  occurs  in  this  condition,  is  found 
the  Staphylococcus  aureus  and  albus  and  other  pus-producing  pyro- 
genic  bacteria.  Even  molds  have  been  found  in  such  cases  by  Auche 
and  Dantec.17  Bujwid18  showed  experimentally  that  an  amount  of 
staphylococci  which  did  not  produce  suppuration  if  suspended  in  an 
indifferent  though  sugarless  fluid,  when  suspended  in  a  similar  though 
sugar-containing  fluid  did  produce  it.  He  also  demonstrated  that  no 
suppuration  ensued  if  the  injection  of  a  subminimal  amount  of  staph- 


DIABETES   IN    SURGERY  243 

ylococci  into  an  animal  were  followed  by  the  injection  of  normal 
saline  fluid,  whereas  the  injection  of  a  sterile  solution  of  sugar  was 
attended  by  suppuration.  If  the  sugar  solution  was  withheld  until 
the  staphylococci  disappeared  from  the  blood,  no  suppuration  resulted. 

These  experiments  were  substantiated  by  similar  ones  of  Nicho- 
las and  Ivarlinski.  In  addition  Nicholas  showed  that  sterile  water 
produced  as  much  damage  if  injected  into  the  cellular  tissue  as 
did  the  sugar  solution.  But  if  an  amount  of  staphylococci  sufficient 
to  kill  an  animal  in  a  few  days  was  injected,  and  followed  by  a  so- 
lution of  sugar,  either  the  animal  was  not  killed  at  all  or  only  after 
a  much  longer  period,  also  a  large  abscess  made  its  appearance  in- 
stead of  a  small  one  or  septicemia.  Ferrero  also  agrees  with  these 
findings  that  sugar  diminishes  the  virulence  of  microorganisms  but  in- 
creases their  pyogenic  properties. 

From  the  foregoing  data  it  will  be  seen  that  a  majority  of  major 
operations  haye  been  and  can  be  performed  with  success  on  diabetics. 
The  percentage  of  mortality  is  27.7  as  reported  by  men  who  have  col- 
lected the  material  on  this  subject.  Such  a  percentage  includes  all 
kinds  of  cases  which  without  glycosuria  would  give  a  high  mortality. 
In  ordinary  cases  in  which  there  has  been  a  preliminary  treatment 
the  mortality  is  hardly  half  this.  Even  in  emergencies  the  percentage 
is  not  more  than  20  to  25  per  cent,  the  percentage  of  sugar  is  not 
always  a  criterion,  since  fatal  results  have  followed  from  coma  when 
sugar  was  temporarily  absent,  and  cases  with  large  amounts  of  sugar 
have  recovered.19 

The  treatment  of  patients  suffering  with  this  complication  must  be- 
gin before  the  operation  is  started.  The  general  treatment  of  the  dis- 
ease can  not  be  entered  into  here,  but  while  this  is  being  carried  out, 
the  following  rules  as  observed  by  most  operators  are  important  to 
remember. 

"1.  No  operation  save  of  the  most  urgent  nature  is  to  be  performed 
if  there  is  over  one  gram  of  ammonia  excreted  in  twenty-four  hours. 

"2.  Acetone  and  cliacetic  acid  must  be  eliminated  from  the  urine 
even  if  the  ammonia  is  normal  before  a  surgical  procedure  is  at- 
tempted. 

"3.  Much  albumin  is  a  contraindication  to  operation  and  even  a 
small  amount  is  of  bad  prognostic  import. 

"4.  Operation  may  be  performed  at  once  in  cases  of  large  pelvic 
tumors,  where  there  is  reason  to  believe  the  glycosuria  is  caused  by 
the  intraabdominal  pressure,  while  in  malignancy  or  in  emergency 
operations  a  very  guarded  prognosis  should  be  given." 


244  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

During  the  operation  the  most  rigid  asepsis  is  carried  out,  and  the 
operation  finished  as  quickly  as  possible,  under  an  anesthesia  of  ni- 
trous oxide  and  oxygen.20  In  all  operations  which  can  he  performed 
under  local  anesthesia,  this  is  the  procedure  of  choice.  Ether  and 
chloroform  are  to  he  avoided  if  possible. 

The  after-treatment  includes  the  general  measures  for  elimination. 
Large  amounts  of  alkalies  are  given  whether  acetonuria  occurs  or  not. 
Morphine  and  codeine  must  not  be  withheld  and  the  diet  should  con- 
tain some  carbohydrates,  as  too  Long  and  too  strict  exclusion  of  this 
food  favors  acetonuria.  If  the  amount  of  sugar  in  the  blood  increases 
while  that  in  the  urine  diminishes,  sodium  bicarbonate  should  be 
given  at  once  intravenously. 

Neuritis  is  a  frequenl  complication  in  diabetic  patients.  In  ad- 
dition to  making  every  effort  to  eradicate  the  sugar  from  the  blood, 
massage  and  electrical  stimulation  is  here  indicated.  Perforating 
ulcers  which  at  times  follow  the  neuritis  are  treated  as  in  any  other 
nicer;  the  font  bathed  frequently  in  warm  water  and  kept  elevated 
and  exposed  to  an  electric  light  which  is  contained  within  a  screen 
which  covers  all. 

Gangrene  has  already  been  mentioned.  Tu  diabetics  particular  care 
must  be  observed  not  to  get  hot-water  bottle  burns.  The  limbs  must 
be  kept  warm  and  the  blood  circulating  freely  by  massage.  If  suf- 
ficient warmth  can  not  be  maintained  by  this  method,  the  electric 
light  treatment  will  prove  an  efficient  means  of  combating  the  diffi- 
culty. If  amputation  is  indicated,  the  rule  of  Gussenbauer14  men- 
tioned  above,  must  be  carried  out. 

Pruritis  can  be  controlled  by  frequent  bathings  followed  by  a  lo- 
tion composed  of  glycerin,  tannic  acid  and  sulphurous  acid  1 ._.  to  one 

dram  each  to  tl nm-e  of  distilled  water.     An  ointment  of  10  grams 

of  menthol  in  an  ounce  of  vaseline  may  be  used  instead. 

The  treatment  of  localized  infections  of  the  skin  such  as  boils,  etc.. 
is  discussed  elsewhere  (q.  v.  .  Other  complications  such  as  albumi- 
nuria, digestive  disturbances,  etc..  are  treated  by  trying  to  eliminate 
the  cause  of  the  diabetes 

The  most  important  and  most  serious  of  the  complications  of  dia- 
betes is  coma.  Three  types  have  been  recognized:21  Kussmaul's  "air 
hunger"  type  or  dyspneic  coma  is  the  most  frequent  of  the  three. 
There  are  usually  premonitory  symptoms  of  lassitude,  headache,  epi- 
gastric pain  and  occasional  vomiting.  The  patient  becomes  restless, 
excited,  and  his  speech  gets  thick  and  finally  incoherent.  The  senses 
grow  duller  and  duller  and  he  eventually  lapses  into  deep  coma.  The 
sufferer  becomes  dyspneic,  at  first  inspiration  is  affected,  later  expira- 


DIABETES    IN    SURGERY  245 

tiou  and  then  the  respiration  becomes  stertorous.  The  respiration  is 
usually  regular  and  not  increased,  but  is  very  noisy,  being  heard  a 
considerable  distance.  The  circumference  of  the  chest  greatly  in- 
creases with  each  inspiratory  effort,  this  demand  for  oxygen  being 
the  reason  for  the  name  ' '  air  hunger. ' '  The  pulse  becomes  fast,  small 
in  volume,  and  of  low  tension.  The  breath  has  a  fruity  odor,  the 
urine  is  loaded  with  acetone  and  all  kinds  of  casts  associated  with 
albumin  and  there  is  general  cyanosis.  Death  usually  occurs  within 
forty-eight  to  seventy-two  hours. 

The  alcoholic  form  begins  with  headache  and  symptoms  suggesting 
alcoholic  intoxication,  the  speech  is  thick,  the  pulse  rapid  and  the 
patient  soon  goes  into  coma,  without  any  distressing  respiratory  symp- 
toms. 

Diabetic  collapse  which  is  sometimes  noted  begins  suddenly.  The 
patient  complains  of  great  weakness  which  is  followed  by  drowsiness. 
The  face  becomes  livid,  the  lips  blue  and  the  extremities  cold;  the 
pulse  which  is  threadlike  is  around  130  to  the  minute,  the  respirations 
are  shallow,  slightly  quickened,  but  not  dyspneic.  The  drowsiness  de- 
velops into  sleep  which  deepens  into  coma  in  which  the  patient  dies ; 
there  is  no  fruity  odor  to  the  breath,  no  acetone  or  diacetic  acid  in  the 
urine.  The  collapse  is  believed  to  be  due  to  heart  failure  induced  by 
myocardial  changes. 

The  cause  of  diabetic  coma  is  attributed  by  Huchard,  Kirstein, 
Corsuda  and  others  to  an  acid  poisoning.  These  acids  though  present 
in  the  normal  blood  are  neutralized  as  has  been  discussed  in  the  chap- 
ter on  acidosis. 

In  this  condition,  however,  the  acids  become  so  increased  in  amount 
that  neutralization  is  impossible  and  the  blood,  being  unable  to  carry 
out  its  functions,  coma  develops. 

When  actual  symptoms  of  coma  have  set  in.  the  treatment  is  almost 
hopeless,  and  the  rule  that  prevention  is  better  than  cure  is  nowhere 
better  illustrated  than  in  this  complication. 

Intravenous  injection  of  a  liter  of  I  per  cent  sodium  bicarbonate 
solution  is  used  after  200  to  400  c.c.  blood  have  been  removed:  in 
addition  subcutaneous  infusion  of  2  per  cent  sodium  bicarbonate  may 
be  employed.  Continuous  proctoclysis  of  2  per  cent  glucose  solution 
in  tap  water  should  be  kept  up.  Large  quantities  of  milk  should  be 
given  by  mouth  at  least  500  to  1000  c.c.  to  which  100  grams  of  levu- 
lose  are  added,  being  used  in  24  hours.  Alkalies  should  be  pushed 
until  the  urine  is  made  alkaline.  This,  however,  is  hardly  possible 
according  to  most  observers.  The  temporary  results  are  often  encour- 
aging, the  respiration  becomes  more  quiet  and  the  patient  may  even 
regain  consciousness.     But  in  the  cases  which  have  been  reported 


246  AFTER-TREATMENT   OF   SURGICAL   PATIENTS 

there  was  a  recurrence  of  the  coma  in  a  few  hours  and  death  occurred 
in  less  than  two  days. 

The  treatment  of  diabetic  collapse  is  the  same  as  that  carried  out 
in  shock  (q.  v.),  which  if  persisted  in  usually  prevents  a  fatal  result. 

Bibliography 

iVerneuil:     Diabete  e1  traumatism^  Bull,  et  mem  Soc.  de  Chir.  de  Paris,  1884, 
p.  373. 

2Smith  and  Durham:     Guy's  Hosp.  Sept.,  1892,  xlix,  343. 

sEedard:     Bull,  de  l'Acad.  de  med.,  Paris,  1894,  series  3,  xxxii. 

<DaCosta:     Modern  Surgery,  Philadelphia,  1914,  W.  B.  Saunders  Co.,  p.  67. 

"Leidv:     Med.  News,  lxv,  357. 

eCohn:     New  York  Med.  Jour.,  1894,  lx,  161. 

"Imlack:      Brit.   Med.  Jour.,   1885,  ii,   61. 

sNeugebauer:     Wien.  klin.  Wehnschr.,  1896,  p.  825. 

oCroom:     Brit.  Med.  Jour.,  1895,  ii,  1360. 
lOBevea:     Am.  Jour.  Obst.,  1900,  xli. 
"Phillips:     Lancet,  London,  1902,  i,  1308. 

i2Konjetzny  and  Weilandj    Mitt.  a.  u.  Grenzgeb.  d.  Med.  u.  Chir.,  1915,  xxviii,  860. 
isVon  Noorden:     Pathologie  des  Stoff  wechsels,  Berliu,  1893,  p.  416. 
"Gussenbauer :     Wien.  klin.  Wehnschr..  1899,  p.  453. 
i5Eulenstein:     Deutsch.  Arch.  f.  klin.  Med.,  1899,  lxvi. 
isNicholas:     Arch,  de  med.  exper.  et  d'anat.  path.,  1896,  viii. 
i^Auehe  and  Dantee:     Arch,  de  med.  exper.,  vi,  853. 
isBujwid:     Centralbl.  f.  Bakteriol.,  iv,  .".77. 
loRislev:      Boston   Med.   and  Surg,  .lour.,  1915,  clxxii. 
-"Morris:     Med.  News,  -Tune  29,  1901. 
ziOsler-McCrae :     Modern  Medicine,  Philadelphia,  1914,  Lea  &  Febiger,  ii. 


CHAPTER  XXX 

NEPHRITIS,  ANURIA,  AND  UREMIC  COMA  FOLLOWING 

ANESTHESIA 

By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Following  an  anesthetic,  albumin  and  casts  may  be  found  in  the 
urines  of  all  classes  of  patients.  From  the  statistics  it  appears  that 
in  more  than  one-third  of  the  cases  this  complication  occurs.  If  this 
condition  was  present  before  the  operation,  it  is  very  apt  to  be  made 
worse  regardless  of  the  anesthetic  used.  Ether  and  chloroform  long 
ago  were  shown  by  Kemp,1  Thompson,2  Buxon  and  Levy,3  and  many 
others  to  be  irritating  to  the  kidneys.  While  chloroform  is  appar- 
ently not  so  apt  to  produce  it,  when  such  damage  does  occur  it  is 
more  extensive,  and  the  effects  last  much  longer.  If  the  kidneys 
are  healthy,  small  amounts  of  neither  drug  is  particularly  irritating; 
but  upon  a  diseased  kidney  the  smallest  amount  will  cause  decided 
renal  irritation,  ether,  of  course,  more  often  than  chloroform,  since 
less  of  the  latter  drug  is  required  for  an  anesthesia.  Grondahl4 
studied  75  cases  following  ether  narcosis  and  found  in  36  per  cent 
albumin  and  casts  which  frequently  did  not  appear  until  the  second 
day.  In  20  per  cent  of  these  patients  the  nephritis  appeared  during 
the  first  day,  while  in  16  per  cent  it  was  seen  on  the  day  following. 
Depending  upon  the  age  of  the  patient,  the  duration  of  the  operation 
and  the  amount  of  ether  used,  the  albumin  and  casts  disappeared 
within  seven  to  ten  days.  In  these  cases  the  operations  were  particu- 
larly long  and  severe  but  the  kidneys  were  apparently  normal  before 
the  operations  were  started.  A  repeated  narcosis  was  followed  by 
the  same  urinary  findings,  but  with  diminishing  severity. 

From  numerous  observations  of  the  urine  it  has  been  found  that 
spinal  and  local  anesthesias  are  also  followed  by  changes  in  this  ex- 
cretion. These  changes  may  appear  in  a  few  hours  or  be  delayed  sev- 
eral days,  disappearing  a  few  days  later.  No  permanent  or  fatal  re- 
sults, however,  have  been  recorded  although  I  saw  one  some  years 
ago.  Tomaschewski  claims  that  60  per  cent  of  spinal  analgesias  and 
66  per  cent  of  local  anesthesias  are  followed  by  changes  in  the  urine 
of  greater  or  less  importance.  Csermak  does  not  find  so  great  a  per- 
centage of  renal  irritation,  but  Hartleib  inclines  to  even  a  greater 
percentage  than  is  claimed  by  Tomaschewski.5 

247 


248  after-treatment  of  surgical  patients 

The  urinary  findings  are  usually  a  trace  of  albumin,  with  hyaline, 
also  finely  and  coarsely  granular  casts.  In  more  severe  cases  in  ad- 
dition, epithelial,  blood  casts,  and  waxy  casts  appear  with  a  con- 
siderable amount  of  blood  in  a  highly  concentrated  urine.  These 
showers  of  casts  very  probably  result  from  the  renal  congestion  due 
to  the  chilling  of  the  relaxed  surface  of  the  body,  from  actual  irrita- 
tion of  the  kidneys  by  the  anesthetic  or  from  the  effect  of  other 
poisonous  substances  upon  the  renal  parenchyma. 

Renal  function  is  interfered  with  during  the  administration  of 
ether,  being  increased  up  to  the  point  at  which  the  corneal  reflex 
disappears,  ceasing  altogether  during  profound  anesthesia.6  Various 
degrees  of  suppression  and  concentration  of  the  urine  occur  with  an 
increase  of  the  chlorides,  urea,  casts,  and  more  or  less  of  albumin,  for 
a  period  of  six  to  ten  days,  at  the  end  of  which  time  the  urine  re- 
turns to  normal.  The  changes  are  aol  so  marked  following  the  ad- 
ministration of  Local  anesthetics,  albumin  only  being  noted  in  a  large 
percentage  of  the  cases. 

Rathery  and  Saison7  have  shown  experimentally  that  ether  inhala- 
tion in  single  or  repeated  administration  is  capable  of  producing 
lesions  in  the  liver  and  kidneys  of  rabbits,  the  liver  particularly  being 
affected.  The  same  is  observed  with  chloroform,  but  the  lesions  are 
much  greater  in  extent. 

Thompson's*  conclusions  concerning  the  effects  of  ether  upon  renal 
function  are  as  follows  : 

"1.  During  ether  narcosis  the  volume  of  urine  secreted  is  affected 
in  two  ways.  In  the  majority  of  experiments  there  is  a  decrease,  in 
a  few  an  increase.  The  hitter  is  probably  an  early  or  light  effect,  the 
former  a  pronounced  effect. 

'"The  depressing  effed  is.  however,  more  marked  than  with  chloro- 
form, and  complete  arrest   occurs  more  readily. 

"2.  The  after-effed  is  less  marked  but  similar  to  that  of  chloroform. 
The  maximum  outflow  of  urine  occurs  about  three  hours  after  removal 
of  the  anesthetic. 

••:!.  The  i »ut | nit  of  nitrogen  with  ether  corresponds  more  closely 
with  its  influence  on  the  outflow  of  urine  than  is  the  case  with  chloro- 
form. In  the  late  stages  of  the  anesthesia,  where  the  urine  volume 
is  decreased,  the  excretion  of  nitrogen  is  diminished  almost  exactly 
to  tin1  same  degree  as  the  urine  volume. 

*'4.  The  efl'eci  of  ether  narcosis  on  the  circulation  of  the  kidney 
differs  also  from  that  of  chloroform.  With  the  former  the  urine, 
when  diminished  in  volume  is,  as  a   rule,  more  concentrated   (contains 


NEPHRITIS,    ANURIA,    AND   UREMIC    COMA  249 

more  nitrogen).     The  converse  was  the  case  with  chloroform.     The 
effect  of  ether  is,  therefore,  primarily  vascular. 

"5.  In  ether  narcosis,  when  the  curves  of  urine  outflows,  kidney 
volume  and  blood  pressure  are  compared,  although  there  is  not  com- 
plete parallelism,  there  is,  on  the  whole,  a  closer  correspondence  than 
is  the  case  with  chloroform.  This  statement  does  not  apply  to  the 
arrest  of  urinary  secretion,  which  occurs  more  readily,  and  with  a 
relatively  higher  blood  pressure  in  ether  than  in  chloroform  nar- 
cosis. 

"6.  The  escape  of  leucocytes  into  the  urine  after  free  ether  nar- 
cosis is  more  marked  than  with  chloroform,  probably  indicating  a 
higher  degree  of  stasis  in  the  glandular  capillaries.  Dilation  of  cap- 
illaries and  escape  of  leucocytes  have  been  noted  by  previous  in- 
vestigations, after  ether  inhalation,  in  the  case  of  other  vascular 
areas  than  renal. 

"7.  An  increased  excretion  of  chlorides  is  seen  after  ether  inhala- 
tion, but  is  much  less,  and  of  shorter  duration,  than  in  the  case  of 
chloroform. 

"8.  Temporary  albuminuria  appears  in  clogs  in  a  much  larger  pro- 
portion of  experiments  with  ether  than  with  chloroform. 

"9.  Reducing  substances,  not  sugar,  which  were  not  present  in  the 
normal  urine,  appeared  in  a  small  number  of  the  experiments  after 
ether  narcosis." 

G-rube9  by  extensive  experimentation  upon  clogs  has  found  that 
these  reducing  substances  are  caused  by  a  disturbed  heat  regulation 
of  the  body.  The  temperature  being  reduced,  the  organism  becomes 
chilled  as  above  stated. 

Primary  acute  nephritis  is  rare  following  anesthesia  and  the  con- 
ditions which  have  been  mentioned  simply  appear  to  be  a  renal  irri- 
tation which  is  more  or  less  transitory,  or  are  the  effects  of  a  pre- 
existing kidney  lesion. 

The  treatment  should  begin  upon  the  operating  table,  in  that  the 
least  possible  amount  of  the  anesthetic  be  used  and  the  patient  not  be 
unnecessarily  exposed  until  the  body  becomes  chilled.  Immediately 
following  the  operation,  plain  tap  water  should  be  given  per  rectum 
by  the  drop  method.  A  salt-free  diet  is  allowed  in  the  bad  cases 
otherwise  a  regular  routine  postoperative  diet,  q.  v.,  is  prescribed. 
A  pitcher  of  water  is  placed  at  the  bedside  and  the  patient  is  encour- 
aged to  drink  all  the  water  possible,  a  glassful  being  ordered  every 
two  hours  in  addition. 

In  spite  of  the  best  treatment  the  diminution  of  the  quantity  of 
urine  secreted  may  become  more  marked,  and  can  even  develop  into 


250  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

the  stage  of  anuria.  Anuria  is,  however,  more  apt  to  be  noted  soon 
after  an  operation,  the  result  of  some  surgical  accident  like  tying  off 
of  ureters  or  the  removal  of  a  solitary  secreting  kidney ;  in  such  in- 
stances, however,  the  patient  will  probably  die  within  forty-eight 
hours.  In  cases  where  the  ureters  are  involved,  the  individual  will 
not  succumb  so  soon,  the  prognosis  being  actually  good  if  the  con- 
dition is  promptly  relieved  by  operation. 

Thomas10  recently  reported  an  anuria  of  five  and  one-half  days' 
standing  in  a  patient  in  whom  nephrectomy  had  been  done  for  py- 
onephrosis four  years  before.  The  remaining  kidney  function  as  de- 
termined by  tests  was  found  to  be  normal  after  recovery. 

Basham11  reported  a  case  in  which  anuria  first  appeared  on  the 
twelfth  postoperative  day  following  nephrectomy  for  hypernephroma. 

This  condition  most  commonly  follows  operations  upon  the  urinary 
tract.  Traumatism  of  the  tissues  in  a  nephrectomy  in  whatever 
method  is  used  to  keep  the  patient  in  the  usual  kidney  position,  tends 
to  cause  this  condition. 

Permanent  drainage  of  a  distended  bladder  or  surgical  shock  is 
followed  at  times  by  anuria,  and  at  times  an  unrecognized  acute 
nephritis  lias  been  the  cause  of  this  serious  complication. 

The  symptoms  which  result  from  this  condition  during  the  early 
stages  are  not  at  all  suspicious  of  any  grave  illness.  The  appetite  is 
poor,  the  patient  is  usually  restless  and  sleep  is  much  impaired,  but 
headache  and  vomiting  may  not  be  present.  In  a  large  proportion 
of  the  c;isrs.  some  urine  is  passed  at  times;  it  is  usually  blood  stained, 
of  low  specific  gravity  and  contains  very  little  urea  or  other  excre- 
tory products.  The  symptoms  are  not  at  all  relieved  by  such  excre- 
tion and  it  does  not  in  any  way  postpone  the  ultimate  result,  which 
is  death,  unless  active  medical,  and  in  many  instances  surgical,  meas- 
ures are  carried  out  to  offsel  such  an  end.  Though  the  mind  remains 
clear,  progressive  muscular  weakness  is  marked;  the  expression  is 
anxious,  the  mouth  and  tongue  become  dry.  the  lips  parched  and  the 
skin  hot.  The  pupils  are  contracted  and  muscular  twitchings  are 
noted  in  many  cases. 

The  patient  becomes  more  and  more  drowsy,  and  while  delirium  may 
occur,  convulsions  are  rare,  while  coma  may  he  absent.  The  pulse 
rate  is  little  affected,  usually  being  slightly  quickened  while  the  tem- 
perature falls  below  the  normal  during  the  last  stages.  The  patient 
is  sometimes  conscious  up  until  the  moment  of  death. 

The  treatment  of  this  condition  must  necessarily  be  active  am' 
efficient.  If  after  eight  hours  the  patient  has  not  voided,  the  forcing 
of  water  should  be  started  as  suggested  in  the  treatment  of  nephritis. 


NEPHRITIS,    ANURIA,    AND   UREMIC    COMA  251 

in  addition  to  continuous  subcutaneous  injection  of  distilled  sterile 
water  free  from  salt.  If  patient  has  not  voided  after  twenty-four 
hours,  catheterize  and  immediately  irrigate  the  bladder  with  a  2  per 
cent  boric  acid  solution.  If  no  urine  is  obtained  or  at  most  an  insuffi- 
cient amount,  even  after  the  above  treatment  has  been  carried  out,  the 
patient  should  at  once  be  surrounded  with  hot-water  bottles  and  the 
region  of  the  kidneys  dry  cupped.  An  electric  light  bath  is  easily 
used  and  proves  most  efficient.  It  may  become  necessary  to  put  the 
patient  in  a  hot  bath,  and  this  is  at  once  followed  by  %  grain  of 
pilocarpine  hydrochlorate  hypodermically.  Such  will  sometimes 
start  the  urinary  secretion.  Thomas'  case  was  efficiently  treated  by 
catheterizing  the  ureter  and  flushing  the  pelvis  of  the  kidney  with 
normal  saline.  The  catheter  was  retained  for  three  days  and  during 
this  time  frequent  irrigations  were  carried  out.  Such  treatment  may 
be  employed  in  addition  to  the  methods  of  producing  diaphoresis.  If 
the  patient's  condition  will  permit,  hydragogue  catharsis  also  may 
be  attempted.  Any  treatment  whatsoever  must  be  carried  out  with 
a  knowledge  of  the  condition  of  the  heart,  and  stimulants  given  if 
necessary. 

If  the  above  measures  fail,  the  kidney  must  be  clecapsulatecl  as 
advised  by  Da  Costa,12  Edebohls,13  Tyson,14  and  others.  The  technic 
of  the  operation  is  as  follows :  The  kidney  is  exposed  by  the  usual  in- 
cision, the  fatty  capsule  is  removed  from  the  true  capsule,  the  dis- 
section being  continued  around  each  kidney  pole  until  the  pelvis  is 
reached.  The  kidney  is  now  pulled  out  of  the  wound  and  the  true 
capsule  incised  along  the  entire  convex  border  and  after  separation 
from  the  kidney  is  cut  away  close  to  its  junction  with  the  pelvis.  The 
kidney  is  then  returned  to  its  bed  of  fat  and  the  wound  closed. 
Drainage  should  not  be  employed  unless  there  is  severe  edema  ac- 
cording to  Ertzbischoff.15 

Uremic  coma  is  to  be  expected  in  elderly  patients  in  whom  a  chronic 
interstitial  nephritis  exists.  It  may  also  occur  in  younger  individ- 
uals who  give  a  history  of  severe  attacks  of  diphtheria  or  scarlet 
fever  in  childhood  with  more  or  less  kidney  symptoms  later  on.  Old 
prostatics  are  particularly  prone  to  this  malady. 

However,  according  to  Willson,lfi  not  all  cases  of  chronic  interstitial 
nephritis  are  subject  to  uremia,  since  neither  sclerosis  of  the  kidney 
nor,  in  fact,  arteriosclerosis  predisposes  to  uremia  until  hypertension 
of  the  vascular  system  is  superadded.  The  two  by  no  means  go  nec- 
essarily hand  in  hand.  Many  cases  of  high  grade  sclerosis  present 
a  comparatively  normal  blood  pressure.  Add  arteriosclerosis  and 
hypertension,  with  its  consequent  intracranial  pressure  to  the  local 


252  APTER-TREATMEXT   OP    SURGICAL   PATIENTS 

toxic  irritation,  and  we  have  at  once  the  ideal  setting  for  the  uremic 
picture. 

The  ultimate  cause  of  the  vascular  hypertension  of  uremia  has  not 
yet  been  discovered.  It  would  appear  by  no  means  impossible  that 
the  intracranial  pressure  is  partly  due  to  toxic  or  inflammatory  ex- 
udate: that  this  causes  hypertension  within  the  cranium,  and  favors 
a  similar  hypertension  throughout  the  general  circulation,  or  vice 
versa  ;  and  that  the  symptom-complex  of  uremia  is  thus  usually  due 
to  such  a  sequence  of  causes.  Probably  uremia  can  not  occur  in  the 
presence  of  low  intravascular  and  intracerebral  tension. 

Usually  if  the  symptoms  appear  after  a  few  days  there  is  a  premoni- 
tion of  the  condition  and  the  patient  complains  of  sleeplessness  fol- 
lowed by  headache,  dizziness,  inability  to  see  plainly,  some  epigas- 
tric pain  and  nausea.  The  blood  pressure  rises  and  the  reflexes  be- 
come exaggerated.  Dyspnea  and  muscular  twitching  may  develop 
with  the  increasing  severity  of  the  symptoms  ami  finally  delirium. 
The  patient  may  now  become  comatose  and  remain  in  this  state  for 
days  until  death  or  convulsions  may  intervene.  "When  these  occur 
the  eyes  roll  upward  and  to  one  side.  the  pupils  dilate,  and  the  pa- 
tient stares.  Then  a  jerking  of  the  angles  of  the  mouth,  the  head 
draws  to  one  side,  and  tiie  neck  and  face  muscles  become  clonically 
convulsed,  this  spreading  to  the  arms,  and  hands,  then  finally  the 
musculature  oi  the  entire  body  is  in  irregular  violent  movements. 
The  face  becomes  cyanotic  and  saliva  is>ues  from  the  mouth.  The 
pulse  gets  rapid,  weal;  and  irregular,  while  Cheyne-Stokes '  respira- 
tion is  the  rule.  Incontinence  of  feces  and  urine  may  be  prevent 
during  the  attack-.  After  a  \'<'w  minutes  the  muscles  become  relaxed, 
the  patient  takes  a  deep  breath,  and  after  a  short  period  in  which  he 
is  dazed,  will  awaken  wondering  what  has  happened.  If  however, 
he  was  in  a  stupor  before  the  convulsion,  sleep,  stupor  or  deep  coma 
will  follow. 

The  treatment  is  based  upon  the  assumption  that  the  poison  which 
is  at  work  is  a  nitrogenous  produd  which  fails  to  be  properly  excreted 
by  the  kidney-.  In  such  eases  a  diet  suitable  to  this  particular  con- 
dition lsas  usually  already  been  carried  out.  Active  elimination 
through  the  kidneys,  bowels,  and  skin  is  the  best  means  we  have  \'.rr 
the  combating  of  this  condition.  Water  must  be  forced  as  described 
under  anuria  and  at  all  times  a  liberal  amount  of  alkali  must  be  sup- 
plied, sodium  bicarbonate  and  sodium  citrate  being  most  generally 
used  under  the  skin  or  intravenous  as  a  matter  of  course.  (See 
Acidosis. 

While  this  treatment    is  being  carried  out  the  heart  must  be  sup- 


NEPHRITIS,    ANURIA,    AND   UREMIC    COMA  253 

ported  with  some  preparation  of  digitalis,  which  is  a  diuretic  as  well 
as  a  cardiac  stimulant,  the  amount  depending  upon  the  symptoms. 

Willson  would  employ  lumbar  puncture  early  in  the  course  of 
uremia  and  repeatedly,  if  necessary,  to  accomplish  the  lowering  of  the 
systolic  blood  pressure.  The  good  results  obtained  by  him  and 
others  by  this  means  very  strikingly  confirm  Cathelin's17  conclusions 
that  there  is  a  constant  intercommunication  between  the  blood  circu- 
lation and  the  cerebrospinal  fluid  by  means  of  lymph  vessels. 

The  following  postdiospital  instructions  are  handed  to  e\^ery  high 
blood  pressure  patient  by  Dr.  Stuart  McGuire  :1S 

Your  wound  has  healed  and  needs  no  further  attention.  From  a  surgical  stand- 
point you  are  well.  From  a  medical  standpoint  you  still  need  observation  and 
treatment. 

Your  watchword  should  be  "Moderation."  This  is  not  because  you  are  an 
invalid,  but  to  avoid  becoming  one. 

Go  slowly.  Moderation  will  serve  you  in  the  wear  and  tear  of  life  like  oil  to  a 
good  machine. 

Work  easily;   exercise  lightly. 

Shortness  of  breath  is  a  signal  to  slow  down. 

Be  temperate  in  all  indulgences. 

Avoid  excitement;  cut  out  worry. 

Eat  sparingly— finish  a  little  hungry  rather  than  replete.  Better  five  small 
meals  than  three  large  ones.  Take  meat  not  more  than  once  clay,  and  sparingly 
then.  No  meat  extracts.  Limit  salt.  Highly  seasoned  foods  are  not  desirable. 
Vegetables,  fruits,  bread,  cereals,  and  milk  should  constitute  your  staple  diet. 
Tea  and  coffee  should  be  used  moderately  if  at  all.  Your  use  of  alcohol  and 
tobacco  should  depend  somewhat  on  your  former  habit.  Decrease  rather  than 
increase.     Drinking  water  should  be  neither  limited  nor  forced. 

Keep  the  bowels  open.  Take  Epsom  or  Carlsbad  salts  once  or  twice  a  week,  if 
necessary,  to  make  them  a  little  free. 

Secure  ample  rest.     Betire  early  and  sleep  late.     Be  a  little  lazy. 

Exercise  regularly  but  not  violently.  Avoid  straining  at  stool.  Cold  baths 
had  better  not  be  used.  Warm  or  tepid  water  is  preferable.  Turkish  baths 
should  not  be  taken  without  the  advice  of  your  physician.  He  is  fully  acquainted 
Avith  what  has  been  done  for  you  and  what  has  been  learned  about  you  while  you 
were  at  the  hospital.     You  should  consult  him  at  reasonable  intervals. 

Many  men  and  women  have  done  the  best  work  of  their  lives,  working  under 
similar  limitations. 

Flease  report  your  condition  at  the  end  of  three  months,  by  mail.  Tf  you  are 
doing  well  the  information  will  help  us.  If  you  are  not  doing  well,  Ave  may  be 
able  to  help  you. 

Bibliography 

iKemp:     NeAv  York  Med.  Jour.,  November,  1899,  p.  732. 

^Thompson:      Brit.  Med.  Jour.,  1900,  i,  833. 

3Buxon  and  Levy:      Ibid. 

^Grondahl:     Deutsch.  med.  Wchnschr.,  1905,  No.  25,  p.  1005. 

5  Allen:     Local  Anaesthesia,  Philadelphia,  1914,  W.   B.   Saunders  Co. 


254  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

eGwathrney:     Anaesthesia,  New  York,  1914,  D.  Appletou  &  Co. 

7Rathery  and  Saison:     Compt.  rend.  Soe.  de  biol.,  1910,  i,  18. 

sThompson :     Brit,  Med.  Jour.,  March,  1906. 

oGrube:     Arch.  f.  d.  ges.  Physiol.,  cxxxviii,  601. 
loThomas:     Journal-Lancet,  1915,  xxxv,  667 
uBasham:     Tr.  West.  Surg.  Assn.,  Denver,  December,  1914. 
i^Da  Costa :     Modern  Surgery,  Philadelphia,  1914,  W.  B.  Saunders  Co.,  p.  1291. 
isEdebohls:     Med.  Eec,  New  York,  December,  1901. 
i4Tyson:     Med.  Eec,  New  York,  July,  1911. 
isErtzbisehoff,  Arch.  Generales  de  Chir.,  April,  1908. 
iGWillson :     Jour.  Am.  Med.  Assn.,  July,  1905. 
i7Cathelin,  Presse  med.,  1903,  iii,  No.  90. 
isMcGuire:      Southern  Med.   Jour.,   1916,  ix,  251. 


CHAPTER  XXXI 

BACTEREMIA    (GENERAL   SEPTIC   INFECTION) 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

The  entry  of  pathogenic  bacteria  into  the  blood  stream,  followed 
by  their  growth  and  proliferation,  is  one  of  the  most  unfortunate  in- 
cidences which  may  arise  during  a  surgical  convalescence.  It  is  in- 
deed a  serious  complication,  one  which  sometimes  causes  a  fatal  ter- 
mination after  an  otherwise  favorable  prognosis. 

The  term  bacteriemia  probably  more  clearly  defines  the  true  nature 
of  the  disease  than  the  older  appellations,  septicemia  or  sepsis,  which 
were  used  during  the  earliest  periods  to  designate  this  condition. 

It  is  common  knowledge  that  bacteria  are  present  in  the  mouth, 
nose,  upper  air  passages,  gastrointestinal  tract  in  all  animals,  where 
they  are  constantly  brought  by  the  air,  food  and  drink.  They  are 
also  found  on  the  skin,  about  the  hair,  and  within  the  sweat  and  se- 
baceous glands.  The  urogenital  tracts  of  men  and  animals  also  pre- 
sent their  goodly  share  of  these  microorganisms.  Despite  the  con- 
tinued presence  of  the  bacteria  on  the  external  and  internal  surfaces 
of  the  body  invasion  of  the  mucous  and  cutaneous  covering  of  same 
is  not  to  any  marked  degree  accomplished,  which  results  in  the  tissues 
and  the  blood,  lymph,  etc.,  being  practically  sterile.1 

The  lowering  of  the  patient's  resistance  through  operative  proce- 
dure or  by  any  other  means  invites  the  microorganisms  to  attack. 
Under  these  circumstances  each  of  the  anatomic  regions  named,  be- 
comes in  addition  to  the  operative  wound,  a  possible  portal  of  entry. 
For  its  defense,  the  body  possesses  a  "protective  mechanism"  which 
consists  in  the  main  both  of  mechanical  and  biological  factors.2  Bac- 
teria which  are  already  present  and  have  become  active  destructive 
agents  through  conditions  mentioned  above  or  through  the  occasional 
visit  of  microorganisms  which  are  seen  only  under  such  circumstances, 
are  met  by  the  mechanical  defense  of  the  body  first.  These,  however, 
are  always  active  even  under  normal  conditions,  for  example,  the 
skin  and  mucous  membranes,  so  long  as  they  are  intact,  form  the  most 
efficient  barriers  the  body  presents.  Mucous  membranes  are  further 
aids  in  this  respect  in  that  they  are,  for  the  most  part,  situated  in 
protected  locations,  and  are  in  some  instances  reinforced  with  cilia, 
which  materially  assist  in  the  mechanical  defense.3  The  eye  is  pro- 
tected from  infection  by  the  mechanical  factors  involved  in  winking, 

255 


256  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

while  the  lacrimal  secretions  carry  away  material  which  may  have 
entered.  In  spite  of  the  close  proximity  of  the  air  and  other  agents 
which  carry  bacteria,  the  conjunctival  sac  is  sterile  in  69  per  cent  of 
the  cases.1  The  respiratory  tract,  though  intimately  associated  with 
air  laden  with  bacteria,  is  practically  sterile  below  the  glottis  as 
shown  by  Jundell.5  Meltzer  believes  this  is  explained  in  part  by  the 
action  of  the  cilia,  which  throw  back  the  bacteria  that  may  have 
passed  the  glottis,  while  those  which  even  the  cilia  fail  to  stop,  are 
taken  care  of  by  the  lymph  nodes  in  the  vicinity.  He  cites  the  obser- 
vations of  Loomis  and  of  Pizzini  who  have  found  living  tubercle  ba- 
cilli in  40  per  cent  of  peribronchial  glands  of  patients  possessed  of 
nontubercnlons  lungs.  The  further  attempt  of  the  body  to  eliminate 
as  many  as  possible  of  the  invaders  is  seen  in  the  action  of  the  various 
sphincters,  which  prevent,  to  a  certain  degree,  the  crowding  of  the 
individual  cavities  with  bacteria.  The  tears,  saliva,  and  mucus,  etc., 
remove  the  microorganisms  which  pass  the  sphincter  sentinels  or  else 
kill  many  through  bactericidal  powers.''  The  number  of  saprophyt- 
ic and  pathogenic  bacteria  which  are  present  in  the  upper  alimentary 
canal  are  but  small  indeed,  compared  to  the  myriads  which  infest  the 
large  intestine.  While  it  is  true  most  of  these  microorganisms  are 
harmless  and  even  useful  as  an  aid  to  digestion,  many  are  patho- 
genic but  their  deleterious  influences  are  outweighed  by  the  action  of 
the  nonpathogenic.  The  intestinal  mucous  membrane  plays  a  most 
important  role  in  keeping  these  bacteria  confined,  yet  according  to 
Adami,7  many  are  brought  into  the  system  proper  through  the  agency 
of  leucocytes  which  are  contained  in  the  lymphoid  tissue  of  the  intes- 
tinal tract.  He  has  shown  that  not  only  the  lymph  nodes  of  normal 
animals  constantly  afford  cultures  of  bacteria,  but  also  properly  pre- 
pared organs,  such  as  the  liver,  kidney,  etc..  from  these  same  animals 
will  reveal  pathogenic  as  well  as  nonpathogenic  bacteria. s  The  net 
work  of  lymphat  Lcs  and  lymph  nodes''  throughout  the  body  const  itute 
another  mechanical  defence,  too  well  known  to  require  extended  men- 
tion. The  further  action  of  the  mechanical  measures  for  defense  is 
exemplified  in  the  carrying  out  of  the  body,  at  least  some  of  the  in- 
fecting agents,  by  means  of  the  secretions  and  excretions  such  as  the 
bile,  sweat,  and  urine.1"  Cohnheim"  considers  the  secretions  of  the 
body  the  chief  agent  of  defense  in  removing  the  bacteria  from  the 
body,  to  which  Meltzer  does  not  agree.  However,  he  says  that  it  is 
a  general  consensus  of  opinion  that  the  toxins  which  always  accom- 
pany these  infections  are  excreted  freely  through  these  channels. 
As  to  the  biological    defensive   mechanism  of  the  body,   it  has  been 

shown   repeatedly  that   if  relatively  virulent   bacteria  are  introduced 


BACTERIEMIA  257 

into  the  blood  stream  of  a  healthy  animal  within  a  comparatively 
short  time,  not  only  do  they  disappear  from  the  blood,  but  also  from 
the  organs  of  the  body  as  well.12  However,  a  like  number  of  the  same 
microorganisms  introduced  into  an  animal  with  some  necrotic  lesion 
as  shown  by  Cheesman  and  Meltzer13  or  even  with  chronic  heart  or 
kidney  disease  or  other  chronic  ailment  as  shown  by  Flexner  soon 
produce  general  bacteriemia  and  death. 

The  power  of  the  body  fluids  and  living  cells  to  kill  and  dispose 
of  bacteria  has  been  known  for  some  time.14  The  alexins  or  "defen- 
sive proteins"  which  have  been  shown  to  possess  marked  bacterici- 
dal powers,  are  the  most  important  defensive  ingredient  of  the  body 
fluids.  The  leucocytes  are  the  cells  most  prominent  in  bacterial  de- 
struction, though  other  cells  of  the  mesodermal  type  are  frequently 
actively  engaged  in  this  work.  Through  positive  chemotaxis,  the  leu- 
cocytes are  attracted  to  the  invading  bacteria,  and  overpowering  them, 
finish  the  destruction  through  phagocytosis. 

The  normal  invasion  of  the  body  by  these  various  bacteria,  Meltzer 
believes  to  be  beneficial ;  he  says  it  means  an  immunization  only 
against  larger  numbers  of  these  same  bacteria  during  periods  of 
lowered  resistance.  Probably  he  has  sounded  a  great  truth :  viz.. 
constant  immunization  makes  general  septic  infection  a  rare  occur- 
rence.    I  feel  that  it  applies  especially  well  to  postoperative  cases. 

The  microorganisms  which  most  often  incite  septicemia  are  the 
Staphylococcus  aureus  or  Streptococcus  pyogenes  or  both.  Less  fre- 
quently the  Staphylococcus  albus.  In  some  cases  the  colon  bacillus 
or  pneumococeus  are  causative  factors.  C4eneral  infection,  however, 
has  followed  the  invasion  of  the  blood  current  by  the  gonococcus, 
Micrococcus  tatragenus.  tetanus  bacillus  or  Bacillus  pyocyaneus.  The 
condition  may  occur  as  a  result  of  a  general  infection  from  any  of  the 
acute  infectious  diseases  which  can  complicate  a  surgical  convales- 
cence. 

In  all  cases  of  suspected  septicemia,  blood  should  be  taken  for  ex- 
amination at  the  onset  of  the  symptoms.  If  negative,  it  should  be 
taken  again  in  a  few  clays.  The  early  observers  along  this  line,  much 
more  frequently  secured  positive  blood  cultures  than  the  later  ob- 
servers. Welch15  showed  this  was  clue  to  faulty  technic  among  the 
former  class  of  men.  He  has  demonstrated  that  the  Staphylococcus 
albus  is  frequently,  if  not  constantly,  present  in  the  deeper  layers  of 
the  skin,  and  that  it  can  not  be  destroyed  by  the  ordinary  methods  of 
cutaneous  disinfection.  It  is.  therefore,  necessary  to  secure  the  blood 
under  aseptic  precautions  from  a  vein,  preferably  the  median  basilic. 
The  blood  is  aspirated  by  a  sterile  glass  syringe,  5  to  10  c.c.  blood 


258  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

being  taken.  Five  c.e.  is  immediately  placed  into  agar  tubes,  kept 
fluid  at  42  C.  at  the  bedside.  Half  the  number  (eight)  after  being 
thoroughly  mixed  with  the  blood  are  slanted  and  cooled.  The  other 
four  are  plated.  Bouillon  tubes  (two  can  also  be  inoculated  with 
the  same  amount  of  blood.  The  material  can  now  be  incubated  and 
in  twenty-four  hours  or  sooner,  be  examined. 

The  prognosis  must  always  be  guarded,  but  it  should  be  hopeful,16 
since  so  much  depends  upon  the  virulence  of  the  infective  bacteria 
and  the  resistance  of  the  patient.  Many  other  factors  also  come  into 
play  which  on  the  whole,  make  the  prognosis  most  unfavorabh 
pecially  when  the  many  possible  complications  are  considered.  The 
finding  of  the  Staphylococcus  albus  in  the  blood  is  not  particularly 
serious  as  Welch  has  pointed  out  and  Bernheim,17  Sittmann,  Pe- 
truschky  and  others  have  reported  eases  which  recovered  when  pure 
cultures  of  streptococci  or  staphylococci  were  found  in  the  blood. 
Pneurnococci  are  particularly  virulent,  but  cases  recovering  from  this 
infection  have  also  been  recorded.18 

Symptoms. — The  symptoms  of  this  condition  are  varied  but  a  typi- 
cal case  would  run  about  so.  Usually  on  the  third  postoperative  day. 
the  temperature  rises  to  102 c  or  more.  There  are  chilly  sensations 
which  may  or  may  not  be  followed  by  chills.  The  patient  may  feel 
miserable.  Sudden  drafts  or  movements  of  the  bed  covers  cause  hot 
flushes.  The  patient  i-  vexed,  irritable,  and  in  many  instances  seri- 
ously concerned,  as  though  he  scented  danger  of  no  little  importance. 
There  is  likely  to  be  headache,  nausea,  pain  in  the  limbs,  back,  or  a 
general  '•ache'*  throughout  the  body.  Thirst  is  pronounced,  the 
mouth  becomes  dry,  the  lips  parched,  and  the  tongue  coated.  Resl 
ness  and  sleeplessness  are  marked.  One  of  the  distinguishing  features 
of  this  disease  is  the  prostration.  Its  extent  depends,  of  course,  upon 
the  virulence  of  the  infecting  microorganism.  As  the  case  progresses, 
the  fever  is  soon  followed  by  a  cold  sweat  during  which  the  tempera- 
ture falls  to  subnormal  at  times.  There  are  usually  morning  re- 
missions and  evening  exacerbations.  The  prostration  increases  from 
day  to  day.  Vomiting  is  the  rule.  The  appetite  is  destroyed  and 
there  may  be  diarrhea.  The  urine  is  scanty  or  may  be  suppressed. 
The  temperature  fluctuates  as  a  rule,  often  rising  very  high  just  be- 
fore death.  The  pulse  is  fast,  soft,  small  and  easily  compressible. 
In  the  aged,  particularly,  will  be  seen  twitching  of  the  muscles  of  the 
hands  and  feet  subsultus  tendinum)  or  twitching  of  other  muscles 
over  the  body,  while  in  children,  convulsions  are  the  rule.  Delirium 
alternates  with  stupor,  which  final]}-  develops  into  coma,  and  usually 
closes  the  scene.    Toward  the  end.  the  facies  become  hippocratic,  pre- 


BACTEREMIA  259 

senting  the  characteristic  hollow  temples,  pinched  nose,  sunken  eyes, 
with  the  cold,  clammy,  leaden  skin.  In  patients  who  live  any  length 
of  time,  there  is  great  emaciation,  loss  of  muscle  tone,  accompanied 
with  pressure  pains  or  toxic  pains  of  neuritis  or  both  together  which 
cause  the  patient  to  cry  out  in  agony. 

The  operative  wound,  if  it  he  the  seat  of  infection,  will  present  the 
cardinal  symptoms  of  inflammation. 

But  in  many  cases  the  focus  of  infection  will  not  be  in  the  operative 
wound.  In  such  patients,  the  diagnosis  may  at  first  be  overlooked. 
However,  the  history  of  the  case  and  the  physical  examination  in  con- 
nection with  the  symptoms  will  decide  the  question  even  in  the  face 
of  repeated  negative  blood  cultures. 

The  spleen  and  liver  become  enlarged,  petechia  are  found  here  and 
there  over  the  body,  and  the  abdominal  muscles  are  board  like,  if 
there  be  accompanying  peritonitis.  In  patients  who  are  overwhelmed 
with  the  disease,  a  leucocyte  count  will  reveal  a  leucopenia.  This  is 
always  in  my  experience  a  grave  sign.  In  cases  of  good  resistance, 
however,  there  will  be  a  marked  leucocytosis. 

Treatment. — The  treatment  first  consists  in  draining  and  thor- 
oughly cleaning  up  the  focus  of  infection  if  this  is  possible.  After 
thoroughly  opening  and  draining  the  wound,  continuous  irrigation 
with  Dakin's  fluid  or  a  hypertonic  salt  solution  is  instituted  as  soon 
as  bleeding  from  the  operative  procedure  has  stopped.  The  work 
must  be  done  under  local  anesthesia.  The  patient  should  be  isolated 
to  prevent  infection  spreading  throughout  the  hospital  and  every 
care  exerted  to  ward  off  contamination  of  the  attendants.  The  tem- 
perature is  controlled  by  cool  sponging  of  the  body  and  an  ice  cap 
to  the  head.  For  the  restlessness  and  general  discomfort,  gentle 
massage  and  alcohol  rubs  are  in  order.  The  extremities  must  be  kept 
warm,  even  if  wrapping  in  cotton  batting  is  necessary  in  addition  to 
the  hot-water  bottles.  The  vomiting  is  controlled  by  the  tube,  one 
which  can  be  left  in  continuously  if  nausea  and  vomiting  are  particu- 
larly bad.  Let  the  patient  assume  any  position  which  is  comfortable. 
Keep  up  continuous  hypodermoclysis,  of  1,000  c.c.  every  6  hours, 
using  plain  freshly  distilled  sterile  water  or  salt  solution.  The  lungs 
must  be  watched  for  edema  in  which  event,  the  water  is  discontinued 
and  atropine  sulphate,  %50  grain,  is  given  hypodermically  every 
three  hours  until  the  danger  signs  disappear.  Use  3  per  cent  glucose 
per  rectum  if  the  stomach  can  not  tolerate  food.  If  one  should  be  so 
fortunate  as  to  retain  nourishment,  frequent  feedings  of  the  most 
nourishing  food  should  be  given.  Under  any  circumstances,  give 
continuous  proctoclysis,  employing  plain  tap  water  in  which  has  been 


260  AFTER-TREATMENT    OP    SURGICAL    PATIENTS 

placed  60  grains  of  sodium  bicarbonate  to  the  quart.  The  heart 
should  be  stimulated  with  some  form  of  digitalis  which  is  also  a 
diuretic. 

If  the  condition  becomes  chronic,  the  patient  is  given  some  good 
tonic  and  exposed  as  much  as  possible  to  sunlight  and  air.  He  should 
be  treated  in  this  respect  the  same  as  are  cases  of  pneumonia,  bron- 
chitis, etc. 

I  have  derived  no  benefit  from  vaccines  or  sera  of  any  bind  in  acute 

cases  though  i  have  no  desire  to  discourage  their  use  in  subacul ■ 

chronic  conditions.  One  striking  resull  was  recently  reported  by 
Freemen   in  the  treatment  of  chronic   pyoeyaneus   infection. 

Bibliography 

iDelafield  and  Prudden:     Text  Book  of  Pathology,  New  York.  1914,  Win.  Wood 
&  Co. 

2Meltzer:     Tr.  Congress,  Am.  Phys.  and  Surg.,  I! v,  li'. 

sBowditch:      Boston  Med.  and  Surg.  Jour.,  1876. 

iLochmitz:     Arch.   i.  Angenh.,  xxx. 

sJundell:     Arch.  E.  Physiol.,   1898. 

sMctehnikoff :      immunity  in  Infectious    Diseases,  Trans.,    1905. 

"\i!;niii:     Jour.  Am.  Med.  Assn.,  December,  L899. 

-Aihimi:      Brit.  Med.  Jour.,  January,  1914. 

oManfredi:     Virchows  Arch.  f.  path.  Anat.,  1899,  civ,  335. 
loFuetterer:      Berl.  klin.  Wchnschr.,   L893,  No.  3. 
nCohnheim:     Quoted   by  Mel1 

i  ■  I ". u x  +  < > 1 1  and  Torrey:     Jinn.  Med.  Research,  L906,  sv,  5. 
i •'•■(  'liccsin.-ni  and  Meltzer:     .lour.  Exper.  Med.,  iii,  p.  533. 
L4Werigo:      Am.  Pasteur,   1894,  viii. 
i5Welch:     Tr.  Cong.  Am.   Phys.  and  Surgs.,  1891,  vii,  1. 
i6Smith:      Keen's  System  of  Surgery,  i. 
i7Bernheim:     Jahrb.  f.  Kinderh.,  1896,  xliii,  208. 
iswhite:     Jour.   Exper.  Med.,   1899,  iv,    125. 


CHAPTER  XXXII 

POSTOPERATIVE  TETANUS 

By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Tetanus  occasionally  follows  operations  even  in  this  day  of  modern 
surgical  asepsis  and  technic.  It  is  a  disease,  infectious  in  nature, 
and  one  characterized  by  tonic  and  clonic  convulsion,  the  muscles 
of  the  jaw  being  first  affected.  The  process  extends  to  the  trunk  and 
then  to  the  extremities,  finally  involving  every  voluntary  muscle  in 
the  body. 

As  a  postoperative  complication,  Wilms1  found  five  cases  after 
herniotomy  during  the  years  from  1868  to  1879'.  In  1886,  Olshau- 
sen2  collected  4.9  cases  following  ovariotomy.  Four  years  later  Phil- 
iyss3  added  61  more  cases  complicating  this  operation,  which  he  had 
collected  during  the  years  preceding  1890.  In  1891,  Brunner4  re- 
ported this  condition  appearing  after  a  goiter  operation.  Five  years 
later  Santos-Fernandez3  observed  tetanus  in  one  patient  after  enu- 
cleation of  the  eye.  In  1897,  Yon  Cackovic6  collected  60  cases  and 
Rose7  during  the  same  year  collected  58  cases  of  tetanus  after  laparot- 
omies. In  1901,  Picherrins  collected  98  cases  after  operations,  upon 
the  female  organs  and  seven  years  later,  Zacharias9  added  72  cases 
more.  Peterson10  in  1910,  reported  19  cases  which  he  had  collected 
during  the  last  twenty  years. 

Previous  to  the  year  1890,  the  reported  instances  of  tetanus  after  op- 
erations occurred  more  frequently  after  laparotomies ;  more  than  half 
of  these  being  ovariotomies.  This  date,  however,  pretty  nearly  marks 
the  beginning  of  the  aseptic  area  and  since  that  time,  there  has  been 
a  marked  decrease  in  the  instance  of  this  complication.  However, 
the  ratio  between  the  cases  of  tetanus  in  which  the  peritoneal  cavity 
was  opened  and  those  in  which  this  portion  of  the  body  was  not  in- 
volved, is  about  the  same  now  as  during  the  preantiseptic  period  ac- 
cording to  Peterson. 

The  instance  of  the  disease  is  more  frequent  in  some  localities  than 
in  others,  but  it  may  occur  in  patients  situated  on  any  part  of  the 
globe,  occurring  in  every  race,  and  especially  in  the  negro.  The  age 
and  the  sex  of  the  patient  have  no  influence  in  the  disease.  Accord- 
ing to  Anders11  tetanus  in.  the  United  States  is  most  prevalent  in 
Pennsylvania,  northern  New  York,  New  Jersey,  Long  Island,  Vir- 

261 


262  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

giuia,  Georgia,  and  southern  Louisiana.  It  is  also  more  frequently 
met  in  Indiana,  Illinois,  and  southern  California  than  in  the  rest 
of  the  states  of  the  Union. 

Tetanus  itself  has  long  been  known.  During  the  age  of  Hippocra- 
tes, the  condition  was  recognized,  and  at  that  early  date,  the  disease 
was  considered  to  have  a  predilection  for  the  nervous  system;  how- 
ever, no  progress  was  made  in  the  study  of  this  condition  until  the 
latter  part  of  the  nineteenth  century  when  Sternberg12  showed  that 
he  could  produce  the  symptoms  of  the  disease  in  animals  by  inject- 
ing dirty  water.  In  188413  these  same  symptoms  were  caused  in  ani- 
mals by  injecting  pus  from  a  patient  suffering  from  tetanus. 

Nicolaier14  during  the  same  year  described  the  tetanus  bacillus, 


Fig.  37. — The  tetanus  bacillus. 

but  it  was  not  until  5  years  later  that  a  pure  culture  of  this  micro- 
organism was  obtained  by  Kitasato.13 

The  tetanus  bacillus10  is  long,  slender,  and  mobile,  often  appearing 
in  pairs;  a  spore  develops  at  one  end  which  gives  it  a  club-shaped 
appearance  (Fig.  37).  It  stains  readily  with  ordinary  stains,  grows 
at  room  temperature  in  the  regular  culture  media,  is  strictly  anaero- 
bic, and  develops  rapidly  in  an  atmosphere  of  hydrogen.  The  ba- 
cillus is  easily  killed  with  ordinary  antiseptics,  but  the  spores,  unlike 
Hie  bacillus,  are  very  resistant  to  chemical  disinfectants,  to  heat,  or 
to  drying.  According  to  most  observers,  exposure  to  n  temperature 
of  100°  C.  for  5  minutes  will  kill  the  spores;  or  a  1:1000  bichloride 
solution  will   destroy   the  spores   in   10  minutes;  a   1  per  cent  silver 


POSTOPERATIVE    TETANUS  263 

nitrate  solution  in  1  minute,  or  1 :1000  solution  of  the  same  in  5 
minutes. 

The  bacilli  are  very  widely  distributed,  their  normal  habitat  being 
in  manure,  garden  soil,  dust  of  the  streets,  walls,  etc.,  but  especially 
in  the  intestinal  tract  of  animals.  As  found  here,  their  virulence  is 
most  marked,  which,  however,  diminishes  in  proportion  to  the  length 
of  time  they  are  outside  the  intestines.17 

The  sources  of  infection  in  postoperative  cases  according  to  Speed18 
are:  the  operator's  hands,  the  instruments,  dressings,  air,  ligatures, 
or  the  patient  himself.  Of  these  avenues  of  infection,  all  are  so 
evident  that  discussion  is  probably  unwarranted,  save  of  the  last  two, 
which  have  until  lately,  been  obscure  points. 

From  the  above,  it  is  not  surprising  that  catgut,  which  is  made 
from  the  intestines  of  animals,  should  be  a  source  of  tetanus  infec- 
tion. There  is  good  proof  on  both  sides  of  this  question,  but  with  the 
development  of  newer  and  better  methods  for  sterilization,  smaller 
size  catgut  is  being  used,  and  the  danger  from  this  source  is  more 
and  more  becoming  lessened.  Richardson19  collected  21  cases  of  post- 
operative tetanus  in  which  catgut  was  considered  at  fault.  It  was 
thought  that  many  of  these  cases  came  from  localities  in  England 
where  tetanic  sheep  were  known  to  be  and  it  was  naturally  supposed 
that  the  sheep  gut  caused  the  infection.  Later  investigation  proved 
that  the  catgut  had  all  come  from  Germany  and  that  the  catgut  which 
was  examined  from  14  of  the  patients,  contained  no  bacilli.  In  19 
of  the  21  cases  collected  by  Richardson,  the  operation  was  a  laparot- 
omy and  the  bowel  was  handled  more  than  usual  or  else  sutured. 
Richardson  mentions  in  this  same  article  the  experience  of  one  oper- 
ator who  performed  five  abdominal  operations  one  morning  and  used 
in  each  case  the  same  preparation  of  catgut.  Two  patients  developed 
tetanus,  but  the  other  three  escaped. 

On  the  other  hand  in  support  of  the  view  that  catgut  is  the  source  of 
infection,  Peterson,  after  extensive  experimentation  with  catgut,  in 
order  to  prevent  just  such  a  calamity  after  a  postoperative  case  of 
his  own  stated:  "I  fear  that  many  operators  who  report  cases  of 
tetanus  after  clean  operations  have  fallen  into  the  same  error  as  I 
in  their  attempts  to  absolve  the  catgut  from  any  part  in  the  causation 
of  the  disease.  At  first  sight  it  seems  reasonable  to  say  it  could  not 
have  been  the  catgut,  because  the  same  material  was  employed  in 
other  cases  with  no  bad  results.  Kuhn,  however,  has  shown  the  fal- 
lacy of  such  an  argument.  He  asserts  that  catgut  is  made  from  the 
intestines  of  sheep  which  exist  under  different  conditions  and  vary 
greatly  in  health.    Every  catgut  thread  contains  fibers  from  four  or 


2,64:  AFTER-TREATMENT    OP    SURGICAL    PATIENTS 

five  different  sheep.  Just  one  of  these  fibers  may  contain  the  tetanus 
bacillus,  while  the  others  may  be  free  from  this  particular  germ.  He 
further  states  that  the  sanitary  conditions  of  the  slaughter  houses 
and  factories  from  which  the  catgut  comes  are  notoriously  bad,  ex- 
posing the  raw  material  to  all  kinds  of  contamination." 

In  June,  1909,  Matas20  reported  two  cases  of  postoperative  tetanus 
following  the  ingestion  of  uncooked  vegetables.  He  directed  atten- 
tion to  the  danger  of  this  infection  even  after  clean  operations  on 
patients  in  whom  the  wound  may  become  contaminated  with  fecal 
material.  This  condition  may  accompany  operations  in  the  region  of 
the  genitourinary  organs  of  cither  sex.  the  sacrococcygeal  or  ano- 
rectal regions,  operations  involving  the  inner  surfaces  of  the  thigh, 
legs  or  any  o1  her  region  of  t lie  body  which  may  come  in  contact  with 
fecal  discharge. 

Matas'  ideas  <• ierning  the  origin  of  tetanus  infection  have  been 

supported  by  many  observers.  Among  those1  may  be  mentioned 
Speed,  who  has  gone  a  step  further,  however,  in  that  he  has  promul- 
gated a  theory  based  on  his  own  observations  and  on  the  experimental 
and  biological  work  which  has  been  done  on  this  subject;  viz.,  that 
the  few  instances  of  postoperative  tetanus  which  develop  in  spite  of 
every  preventive  means  are  due  to  tetanus  carriers.  He  thinks  it 
very  probable  thai  some  human  beings  carry  and  excrete  the  organism 
for  long  periods  of  time.  Considering  such  individuals  ;is  surgical 
patients,  he  s;iys,  "Their  greatesl  danger  is  to  themselves  because 
after  operative  procedures  which  permit  fecal  contamination  of  the 
wound,  tetanus  may  be  inaugurated.  This  is  particularly  true  of  ab- 
dominal operations  where  the  gul  is  bruised  or  roughly  handled  and 
opportunity  for  tetanus  development  ensues  in  accordance  with  the 
pathologic  requirements." 

Formerly  it  was  taughl  that  tetanus  was  not  an  infection  in  the 
sense  that  the  bacilli  entered  the  blood  stream  or  any  organ.  The 
toxins  produced  by  the  growth  and  proliferation  of  the  organisms 
which  were  present  within  the  wound  were  alone  considered  the 
agents  which  produced  the  symptoms.  During  recent  years,  however, 
the  bacilli  have  been  found  in  lymph  glands,21  in  the  blood  stream,22 
in  muscles,  in  the  spinal  canal,  in  nerves  and  even  the  brain23  itself. 
of  patieids  infected  with  tetanus.  Positive  cultures  of  the  tetanus 
bacillus  have  been  grown  on  several  occasions  from  the  blood  of  pa- 
tients suffering  from  this  disease.  It  mattered  little  whether  the 
blood  was  taken  at  the  site  of  the  infection  or  from  some  other  region 
of  the  body.  Sclinitxler-'  obtained  the  bacilli  from  a  lymph  gland 
as   well    as    from    the   blood   stream   and   succeeded    in    getting  positive 


POSTOPERATIVE    TETANUS 


265 


results  by  animal  inoculation  from  both  these  sources.  According 
to  Meyer  and  Ransom25  the  toxin  produced  by  the  tetanus  bacilli 
reaches  the  spinal  cord  through  the  agency  of  the  motor  nerves  only, 
but  Jacobson  and  Pease26  state  that  other  nerves  are  involved  as  well, 
since  the  toxin  is  present  in  the  blood  and  lymph  as  well  as  in  the 
axis  cylinders  of  the  motor  nerves  which  are  especially  affected  be- 
cause in  the  lymph  spaces  their  bared  endings  are  particularly  ex- 
posed to  the  poison.  Once  in  the  cord  the  motor  cells  are  attacked, 
pathologic  changes  being  produced  as  noted  in  other  infections  and 
the  toxin  ascends  the  motor  tracts  to  the  medullary  centers  where 
further  destruction  of  the  nervous  tissue  is  consummated.  Meyer  and 
Ransom  further  state  that  the  basis  of  this  disease  is  a  spreading  irri- 
tation of  the  motor  neurones  of  the  cord,  which  produce  the  tonic 
contractions  of  the  muscles,  and  an  extreme  reflex  excitability  due  to 
poisoning  of  the  sensory  neurones  which  causes  the  clonic  convulsive 
seizures. 

The  symptoms  of  this  dreaded  disease  appear  within  ten  days  in 
four-fifths  of  the  postoperative  cases  reported  by  Peterson  as  col- 
lected since  1890.  In  the  remaining  one-fifth,  the  initial  symptoms 
did  not  appear  until  the  eleventh  to  the  twenty-second  day.  The 
usual  incubation  period  of  the  tetanus  bacillus  is  from  3  to  5  days. 
It  is  considered  that  the  shorter  the  incubation  period  the  more  in- 
tense will  be  the  symptoms  and  the  quicker  will  be  the  fatal  termina- 
tion of  the  disease. 

Elvler,27  who  had  contracted  the  disease  while  operating  on  an 
infected  patient,  lived  to  tell  of  the  symptoms  which  he  experienced. 
He  stated  that  the  earliest  manifestations  of  it  were  very  short  and 
transient  in  nature,  and  were  attributed  to  the  healing  wound.  This 
felt  hot  and  uncomfortable  and  darting  pains  were  noted  before  any 
swelling  or  redness  occurred.  Among  other  important  symptoms 
he  mentioned  headache,  sleeplessness,  restlessness,  difficult  respiration, 
dizziness,  chilly  sensations,  with  frequent  and  difficult  urination. 
Later  the  symptoms  assumed  the  form  which  have  been  considered 
characteristic  of  the  malady. 

Stiffness  of  the  jaw  is  most  commonly  first  to  be  noted  by  the  pa- 
tient. This  is  very  soon  followed  by  stiffness  of  the  neck.  As  the 
disease  progresses,  other  muscles  become  involved  until  finally  every 
voluntary  muscle  in  the  body  is  stimulated  to  tonic  contracture.  Any 
sensory  stimulation  such  as  drafts,  sounds,  lights,  even  the  touching 
of  the  bed  or  the  contact  of  the  bed  covers  will  cause  clonic  seizures 
in  addition  to  the  tonic  convulsions  from  which  the  patient  is  already 
suffering.      There  is   constipation,    and   in   some   instances   retention 


266 


AFTER-TREATMENT    OF    SURGICAL   PATIENTS 


of  urine  clue  to  sphincter  spasm.  Irritation  of  feces  or  urine  or  at- 
tempts at  deglutition  will  bring  on  sudden  fearful  clonic  convulsions 
in  which  he  may  injure  himself.  Teeth  are  frequently  broken  and 
muscles  ruptured  during  the  hardest  spells.  Naturally  such  a  dis- 
ease will  cause  the  patient  to  assume  all  sorts  of  hideous  postures 
(Fig.  38)  which  are  temporarily  exaggerated  during  the  clonic  con- 
vulsions, but  probably  the  worst  feature  of  the  whole  picture  is  the 
clearness  of  mind  which  the  patients  possess  throughout  the  entire 
period  of  suffering,  even  until  the  end.  Death  occurs  usually  within 
four  days  in  patients  whose  symptoms  appeared  within  ten  days  of 
the  operation,  but  one  case  reported  by  Peterson  lived  twenty-five 
days.  The  mortality  as  shown  by  a  study  of  his  cases  is  85  per  cent. 
Treatment. — The  treatment  of  this  disease  first  seriously  concerns 
itself  with  preventive  measures  undertaken  to  offset  such  unfortunate 


*  tnus. 

occurrences.  Matas  recommends  that  patients  about  to  undergo  op- 
erations which  involve  areas  subject  to  fecal  contamination  should 
abstain  from  such  foods  as  vegetables  or  fruits  which  have  not  been 
thoroughly  cooked.  In  addition,  fret'  catharsis  three  or  four  days 
before  should  be  instituted.  In  cases  where  such  preparation  can  not 
be  made  or  in  patients  living  in  Idealities  where  the  disease  is  es- 
pecially prevalent,  Matas  advises  a  prophylactic  dose  of  antitoxin. 

If,  in  spite  of  such  treatment  the  symptoms  appear,  or  even  if 
there  is  a  suspicion  of  such  a  condition,  the  patient  should  be  moved 
into  a  darkened  room  which  is  well  ventilated.  I'vrr  from  the  ordinary 
noises  of  an  institution,  and  cwvy  effort  should  be  put  forth  to  ex- 
clude possible  sources  of  peripheral  irritation.  At  once,  administer 
pi  to  30  e.c.  of  antitoxin  subcutaneously  near  the  draining  wound 
if  one  is  present;  but  if  the  fluid  scrum  be  not  available,.  1  gram  of 


POSTOPERATIVE   TETANUS  267 

the  powder  dissolved  in  each  10  c.e.  sterile  water  may  be  used  in- 
stead. Such  a  close  should  be  given  every  6  or  8  hours  until  there 
is  improvement.  Then  half  of  this  amount  is  administered  and  as 
the  symptoms  abate  the  amount  is  still  further  cut  clown  and  the  in- 
terval of  administration  increased. 

Give  plenty  of  soft  solid  or  liquid  foods  with  liberal  amounts  of  al- 
kalies. If  deglutition  causes  severe  pain  or  brings  on  convulsions, 
feed  the  patient  per  rectum.  It  may  be  possible  to  partially  anesthe- 
tize the  pharynx  with  cocaine.  After  this  measure,  food  can  be  intro- 
duced through  a  stomach  or  nasal  tube. 

If  the  wound  has  healed,  particularly  one  about  the  extremities, 
it  should  be  opened  widely  and  large  cigarette  or  rubber  drains  placed 
in  every  angle.  The  wound  is  then  washed  out  with  1 :1000  silver  ni- 
trate solution,  or  tincture  of  iodine  which  has  been  diluted  to  one- 
third  its  strength  with  alcohol.  After  a  few  hours  when  the  bleeding 
stops,  remove  the  dressing  and  irrigate  continuously  with  Dakin's 
fluid,  leaving  only  a  few  layers  of  gauze  over  the  wound  to  assist  in 
caring  for  the  drainage.  The  affected  portion  is  then  placed  under  a 
cradle  which  supports  several  electric  light  bulbs  or  else  exposed  di- 
rectly to  the  sun's  rays. 

Careful  attention  should  be  given  the  bowels,  as  detailed  under  the 
headings  "cathartics"  and  "enemas."  Water  freely  given  by 
mouth,  by  rectum  or  under  the  skin  will  greatly  aid  urination. 

Sleep  and  rest  is  secured  by  giving  per  rectum  chloral  hydrate  or 
chloretone  in  warm  olive  oil;  30  grains  of  the  former  or  60  grains 
of  the  latter,  may  be  given  at  one  dose.  It  may  be  necessary  to  em- 
ploy some  form  of  opium  to  get  the  desired  rest  and  sleep. 

In  violent  cases  of  tetanus,  40  to  50  c.c.  of  antitoxin  is  given  as 
above.  "Walther28  has  recently  noted  that  closes  as  large  as  760  c.c. 
have  been  administered  within  twelve  hours.  "He  recommends  intra- 
spinous  injection  which  he  claims  gives  better  and  quicker  results 
and  much  smaller  amounts  of  the  serum  are  needed.  Following  the 
injection,  he  places  the  patient  with  the  head  clown  for  a  short  period 
of  time.  Magnesium  sulphate  may  be  employed  for  the  constant  mus- 
cular contractions  which  will  soon  exhaust  the  patient  unless  relieved. 
Burge29  has  recently  reviewed  the  work  on  this  chemical  which  has 
been  shown  to  be  an  efficient  agent  for  stopping  pain  and  producing 
sleep.  Kocher30  has  reported  good  results  from  its  use.  He  employs 
10  c.c.  of  a  15  per  cent  solution  of  the  chemically  pure  salt.  If  the 
severity  of  the  case  warrants  it,  2  to  5  c.c.  of  a  25  per  cent  solution  are 
used,  repeated  two  to  four  times  during  the  twenty-four  hours.  It 
is  usually  given  subcutaneously,  but  if  quick  results  are  imperative, 


268  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

this  dose  may  be  given  intravenously  or  intraspinously.  Calcium 
chloride,  an  antagonist  of  magnesium  may  be  administered  to  pa- 
tients receiving-  this  treatment,  which  endangers  the  respiratory  cen- 
ter at  times.  Magnesium  sulphate  should  be  given  only  to  the  point 
of  controlling'  the  convulsions,  though  some  stiffness  of  the  muscles 
will  still  he  present.  Kocher  says  that  so  long  as  this  rule  is  followed, 
the  respiratory  center  will  not  he  paralyzed.  The  drug  should  not  he 
given  in  quantities  in  excess  of  1%  grains  of  magnesium  sulphate 
to  2\o  pounds  of  body  weight  during  the  twenty-four  hours.  Chil- 
dren, especially,  do  not  take  kindly  to  this  treatment,  and  particular 
care  must  be  observed  in  its  use  among  them. 

Patients  in  whom  satisfactory  results  are  not  obtained  with  the 
antitoxin,  chloral,  ehloretone  and  magnesium  sulphate,  should  ac- 
cording to  Hercher31  he  given  15  c.e.  of  ether  in  750  c.c.  normal  salt. 
The  dose  can  he  repeated  as  often  as  indications  warrant. 

Bibliography 

iWilms:     Quoted  bj   Speed:     Surg.,  Gynec.  ami  Obst.,  1916,  xxii.   147. 

iOlshausen:     Eandb.  f.  Frauenkrankheiten,  L886. 

sPhillyss:     Med.  Chir.  Tr.,  1892,  bcxv,  135. 

*Brunner:      Beitr.   /..  klin.  Chir.,   L891,  xii. 
Santos-Fernandez:      Rev.  gen.  d'ophth.,   1896. 

6Von  Cackovic:     Centralbl.  .1.  Chir.,  1897,  xxiv,  728. 

"Rnsr:      Der  Starrkrampf  beim  Menschen  Deutseh.  Chir.,  Lief  s.  L897. 

sPieherrin:     Jour.  Med.  de  Bordeaux,  1901,  p.  52. 

''Zarliai  ias :      Miinchen.    med.   Wehnschr.,    1908. 
^Peterson:     Jour.  Am.  Med.  Assn.,  1910,  liv,  11". 
nAnders:     Jour.  Am.  Med.  Assn..  July,  1905. 

aberg:      Manual  of  Bacteriology,  New  York,  Wm.   Wood  &  Co. 
I  arle  ami   Rattone-:     Grior  della  R.Acad,  di  Med.  di.  Torino,  1884. 
L*Nicolaier:      Deutseh.   Med.   Wehnschr.,    1884. 
i5Kitasato:      [bid.,  1889,  xv,  635. 
isDelafield  ami   Prudden:     Text    Booh  of  Pathology,  1914,  New  Fork,  Wm.  Won. I 

&   Co.,   p.   286. 
'  •Snurnni :     Verhandb.  d.  X.  internat.  Med.  Cong.,  Berlin,  1890. 
isSpeed:     Surg.,  Gynec.  ami  Obst.,  1916,  xxii,   117. 
isRichardson :      Brit.   Med.  Jour.,   1909,  i.  948. 

■Mains.      Tr.  Am.  Surg.   Assn.,   wii,    10. 

'I'urtrr  and  Richardson:     Boston  Med.  ami  Surg.  Jour.,  December,  1909. 
22Reinhardt:     Centralbl.   i.    Bakteriol.,   Ixix.  583. 
23Haegler:     Beitr.  z.  klin.  Chir.,  1889,  \.  No.  1. 
-'S.-imit/.lci  :     Centralbl.    t    Bakteriol.,  xiii.   »i7«.'. 

Meyer  ami  Ransom:     Arch,  exper,  Path.  u.  Pharmakol.,  1903. 
26Jacobson  and    Pease:      Ann.  Surg.,  September,    1906. 
27Elvler:     Quoted  by  Da  Costa,  Modern  Surgery,  1914,  Philadelphia,  W.  I;.  Saui 

dcr-  Co..  p.  206. 
28Walther:      Bull,  el    mem.  Soe.  ^\r  Chir.  de  Paris,   1915,  \li.  1904, 
29Burge:     Jahresb.  f.  Arztl.    Portbild.,    1915,  \i.  .".. 

"Kocher:      A.bstr.    Intermit.  Jour.  Surg.,    l!»lii.  xxii. 
31Hercher:     Miinchen.  med.  Wehnschr.,  1915,  lxii,  lli'ii. 


CHAPTER  XXXIII 

GAS  BACILLUS  INFECTION 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Since  the  days  of  Lister,  gas  bacillus  infection  has  so  decreased  in 
frequency  as  to  be  considered  now  as  one  of  the  rare  complications 
following  surgical  procedures.  The  condition  was  described  as  early 
as  1853,  by  Maisonneuve,1  who  gave  it  the  name  of  "gangrene  foud- 
royante."  Pirogoff2  in  writing  on  this  same  subject  in  1864,  consid- 
ered the  affliction  an  "acute  gangrenous  edema."  Later  on  it  was  re- 
vealed that  the  disease  could  be  transmitted,  but  it  was  not  until 
1891  that  the  cause  of  this  malady  was  made  known  through  the  dis- 
covery of  the  Bacillus  aerogenes  capsulatus  by  Welch.3  Two  years 
later,  Fraenkel4  described  the  organism  which  produced  "gas  phleg- 
mon" which  proved  to  be  the  same  as  the  one  described  by  Welch. 
Further  investigation  by  others  demonstrated  this  microorganism  in 
wounds  characterized  by  the  formation  of  gas,  and  the  identity  of  the 
bacterium  became  established.  Nothing  of  material  importance  has 
been  added  to  the  work  of  Welch  on  this  subject,  except  Dunham's 
discovery  in  1897,  that  this  microorganism  produces  spores. 

Bacillus  aerogenes  capsulatus  (gas  bacillus)  is  rather  large,  short, 
thick  and  sometimes  curved  with  rounded  ends.  It  grows  in  the  ordi- 
nary media  at  room  or  body  temperature  only  under  strict  anaerobic 
conditions.  In  this  respect,  it  resembles  the  tetanus  bacillus.  It  is 
a  spore-forming,  nonmobile  organism  which  takes  the  ordinary  aniline 
dye  stains  and  is  Gram-positive.  It  is  often  encapsulated  and  some- 
times forms  chains.  It  is  readily  killed  by  exposure  to  58°  C.  tem- 
perature for  ten  minutes.  The  growth  of  the  bacillus  brings  about 
a  splitting  of  the  protein  or  sugar  which  results  in  a  gas  being  formed 
consisting  mostly  of  hydrogen ;  carbon  dioxide  and  nitrogen  are  also 
present.  It  burns  with  a  pale  blue  flame.  The  natural  habitats  of  the 
organism  are  the  soil,  and  the  intestinal  tract  of  animals.  It  has  been 
repeatedly  demonstrated  in  the  feces  of  man. 

Infection  with  this  microorganism  in  postoperative  cases  is  rare, 
yet  it  occurs  often  enough  to  demand  attention.  It  most  frequently 
follows  emergency  operations  on  patients  with  crushing  injuries,  par- 
ticularly of  the  lower  extremities.  Coal  miners,  trainmen,  soldiers 
and  laborers  especially  exposed  to  the  soil  are  more  apt  to  be  the  vic- 

269 


270  AFTER-TRF.ATMI'.XT    OF    SUttGICAL    I'ATII'.XTS 

tims  of  this  malady  than  the  regular  hospital  operative  patient. 
Swan,5  Bolby  and  Rowlands''  and  many  others  have  recently  reported 
the  condition  following  all  sorts  of  injuries  and  operations  necessitated 
by  the  same,  in  the  great  World  War.  In  every  case,  however, 
the  tissues  were  either  badly  bruised  or  else  contaminated  with  dirt,  or 
both.  Tissues  whose  resistance  has  been  lowered  by  contusion  or  de- 
prived of  the  normal  blood  supply  have  been  shown  by  all  investi- 
gators on  the  subject  to  be  especially  good  media  for  the  growth  and 
development  of  the  Bacillus  aerogenes  capsulatus.  Operations  about 
the  groins,  inner  portions  of  the  thighs,  upon  the  male  or  female  uro- 
genital organs,  in  the  anosacral  region,  or  in  any  portion  of  the  body 
where  fecal  contamination  is  possible,  may  result  in  this  infection. 
It  has  followed  appendectomy  and  other  operations  upon  the  gastro- 
intestinal tract.  Curettage  following  abortions  has  also  been  compli- 
cated by  this  disease.  Of  the  cases  reported  by  Blake  and  Lahey7 
three  were  crushing  injuries  to  the  extremities,  four  were  compound 
fractures,  and  one  a  laceration  of  the  scalp.  In  each  instance  the 
wounds  were  contaminated  with  soil.  One  followed  opening  of  a 
deep  gluteal  abscess  and  one  occurred  after  amputation  of  the  leg  in 
a  diabetic.  In  1011,  Hewitt^  reported  ten  more  cases.  These  were 
the  result  either  of  wounds  becoming  contaminated  with  dirt  and 
necessitating  operation  or  the  infection  developed  in  several  trauma- 
tized wounds  which  later  required  operation. 

Gilpatrick9  reported  this  complication  after  a  hemorrhoid  operation 
with  opening  of  an  ischiorectal  abscess.  Hewitt  says  the  rarity  of  this 
infection  in  such  eases  is  due  to  leaving  the  wound  Avide  open,  the 
bacillus  being  unable  to  grow  in  the  presence  of  oxygen  which  the  air 
contains.  He  further  states  that  such  infections  do  not  develop  in 
very  many  eases  of  soil  contaminated  wounds,  hence  it  would  seem 
that  purification  of  tissue  and  injured  blood  supply  favor  bacillus 
aerogenes  infection  owing  to  weak  or  absent  resistance.  The  presence 
of  this  microorganism  on  amputation  slumps  without  infection  in 
other  reported  eases,  he  says,  bears  out  his  conclusions.  Recently. 
Dudgeon10  stated  that  gas  gangrene  is  produced  by  this  infection 
alone  in  "especially  abnormal  tissue."  Otherwise  ordinary  suppura- 
tion will  result.  He  obtained  cultures  of  the  bacillus  from  cases  of 
peritonitis,  puerperal  fever,  bone  abscess  and  cystitis,  in  which  no 
evidence  of  this  condition  was  apparent. 

The  symptoms  are  those  of  a  severe  toxemia.  In  the  milder  eases, 
there  is  a  slight  rise  of  temperature  and  pulse,  but  the  patient  appears 
much  more  ill  than  the  physical  examination  denotes.  The  wound 
presents  a  dark,  thiekish,  bloody  discharge  in  which  a  few  bubbles  of 


GAS  BACILLUS  INFECTION  271 

gas  may  be  present.  The  wound  is  not  red,  but  appears  to  be  covered 
with  a  decomposing  black  blood  clot  from  which  gas  bubbles  may  be 
pressed.  There  is  a  vile,  penetrating,  pungent  odor  as  of  stagnant 
blood  enclosed  in  a  cavity,  which  very  soon  will  permeate  a  whole 
hospital  ward.  The  immediately  surrounding  skin  is  brown  in  color, 
and  looks  ecchymotic  except  for  the  fact  that  there  is  no  mottling. 

In  more  severe  types  of  the  infection,  the  patient  not  only  looks 
sick,  but  on  examination,  will  instantly  convince  one  that  he  is  se- 
riously ill.  The  temperature  is  high  (104°  F.)  with  a  rapid  pulse  and 
respiration  and  before  the  dressings  are  removed  from  the  wound, 
the  odor  will  man}'  times  confirm  suspicions  as  to  the  real  nature 
of  the  trouble.  The  incubation  period  of  the  bacteria  being  only 
twenty-four  hours,  the  disease  progresses  rapidly.  "Within  a  few 
hours,  the  wound  will  look  as  though  a  hot  iron  has  been  seared  over 
its  surface,  being  dry  and  black,  or  it  may  present  a  grayish  slough.11 
At  the  end  of  twenty-four  hours,  swelling  is  very  marked,  the  skin 
is  drawn  tense  and  becomes  shiny.  Palpation  elicits  crepitus  due  to 
the  gas  within  the  tissues.  At  the  end  of  forty-eight  hours,  if  the  pa- 
tient lives  this  long,  the  face  assumes  a  "greenish  pallor,"  the  ex- 
pression is  anxious  but  he  rarely  complains  of  any  pain.  The  nature 
of  the  infection  produces  necrosis  and  with  the  pressure  of  the  gas, 
nerve  conductivity  is,  no  doubt,  seriously  interfered  with,  this  ex- 
plaining the  absence  of  pain.s  The  temperature  and  pulse  remain 
high  until  the  end.  This  is  probably  due  to  the  additional  infection 
with  other  microorganisms. 

The  gas  dissects  along  the  fascial  planes  and  follows  the  lines  of 
least  resistance.  The  tendons,  ligaments  and  fascia  resist  the  infec- 
tion, but  the  injured  muscle  certainly  furnishes  good  media  for  the 
rapid  growth  of  the  bacillus,  hence  pulpifies  early.  The  lymph  glands 
are  rarely  affected,  probably  due  to  the  rapidity  of  the  disease. 

Nausea  and  vomiting  occur  late,  as  does  the  delirium  which  is  an 
indication  of  a  general  infection.  Recovery  is  not  the  rule  after  the 
third  day. 

The  mortality  has  gone  as  high  as  90  per  cent  among  soldiers  in 
some  past  wars.  Recently,  Gamble12  reported  45.5  per  cent  mortality 
in  a  small  number  of  patients.  Bell  insists  that  it  should  be  nil  if 
treatment  is  instituted  early  enough. 

The  treatment  for  this  condition  starts  at  the  time  the  patient  is 
received  if  the  nature  of  the  case  causes  suspicion  of  such  a  compli- 
cation developing.  The  wound  must  be  thoroughly  cleansed  of  all 
foreign  particles.  In  these  cases  of  crushing  injuries  or  fractures 
contaminated  by  dirt  or  grease  to  prevent  this  infection  wide  and  deep 


272  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

incisions  should  extend  through  the  muscles  and  down  to  the  bone; 
large  rubber  or  cigarette  drains  should  be  placed  in  every  one  of  them; 
each  wound  should  be  continuously  irrigated  with  Dakin's  fluid,  or 
a  hypertonic  sodium  chloride  solution.  A  cradle  can  be  placed  over 
the  parts  and  the  wound  exposed  to  the  rays  of  electric  light  bulbs. 
At  the  first  sign  of  the  disease,  at  once  start  a  stream  of  oxygen  into 
every  recess  of  the  wound  by  means  of  catheters,  in  addition  to  the 
treatment  already  outlined.  If  in  spite  of  the  oxygen  and  the  con- 
tinuous irrigation,  the  disease  progresses,  there  is  nothing  left,  ac- 
cording to  most  writers,  but  to  amputate  the  extremity  high  up  (for 
it  will  most  likely  be  in  an  extremity),  and  keep  the  stump  open. 
maintaining  the  stream  of  oxygen. 

Amputation  is  still  a  debatable  procedure  in  this  disease  as  it  set  ins 
to  me.  At  the  St.  Louis  City  Hospital  in  1910-1912  several  patients 
were  lost  after  amputation,  then  a  number  of  successes  were  scored 
under  rather  similar  circumstances  where  no  amputation  was  done. 

Bibliography 

LMaisonneuve :     Gaz.  med.  de  I'aiis.  Is.".:;,  p.  592. 

apirogoff.     Grundziige  der  allgemeinem    Kriegschr.,   Leipzig,   1864,   p.  867. 

'Welch  and  Nuttall:     Bull.  Johns  Hopkins  Hosp.,  1892,  Hi,  p.  81. 

tFraenkel:     Uber  Gasphlehmonen,  Eamburg  and  Leipzig,  1893. 

-Sw.-in  :     Lancet,  London,  1914,  ii,  1  l'il . 

6Bolby  ;iikI   Rowlands:     Lancet,  London,  1!>14.  ii,  1161. 

"Blake  ami   Lahev:      Jour.   Am.    Med.   Assn..    1910,   liv.    1671. 

sHewitt:     Jour.  Am.  Med.  A.ssn.,   1911,  lvi.  960. 

aGilpatrick:      Boston   Med.  ami   Surg.  Jour.,    1910,  clxii,   741. 
icDudgeon:      Lancet,  London,    1914,   ii.    L385. 
uBell:     British  Med.  Jour.,  May  1.1.  1915,  p.  843. 
^Gamble:     Internat.  Join-.  Surg.,  1916,  xxviii,   t02. 


CHAPTER  XXXIV 

POSTOPERATIVE  PNEUMONIA 

By  0.  F.  McKittrick,  St.  Louis,  Mo. 

The  occurrence  of  pneumonia  in  postoperative  patients  has  always 
been  considered  a  serious  complication,  probably,  one  which  the  sur- 
geon considers  first,  and  measures  taken  to  prevent  this  one  accident 
alone  may  be  seen  during  the  course  of  operation  in  any  hospital  on 
the  globe. 

Experience  has  long  ago  taught  that  a  disease,  so  destructive  to 
life,  and  yet  one  so  easily  preventable,  commands  serious  attention. 

In  spite  of  the  modern  methods  of  operating  and  the  infinite  care 
exhibited  in  surgical  patients,  in  order  to  prevent  the  disease,  there 
are  still  evidences  that  more  can  be  done  to  further  decrease  its  in- 
stance. The  efforts  already  put  forth  have  cut  the  number  of  cases 
reported  to  a  small  item  compared  to  the  many  thousands  of  individ- 
uals who  are  yearly  subjected  to  the  knife.  Statistics  are  of  little 
value,  but  may  give  some  idea  of  the  frequency  with  which  the  condi- 
tion occurs  in  the  hands  of  the  very  best  surgeons. 

Beckman1  found  pneumonia  27  times  in  reviewing  the  complications 
which  occurred  in  6.825  surgical  operations  at  the  Mayo  Clinic  dur- 
ing the  year  1913.  Risley,2  in  1910,  reported  15  cases  of  pneumonia 
occurring  after  1000  consecutive  laparotomies  at  the  Massachusetts 
General  Hospital,  and  5  cases,  after  920  other  operations,  not  lapa- 
rotomies, on  various  portions  of  the  body.  Quite  recently,  Whipple3 
collected  42  cases  out  of  1002  operations  performed  at  the  Presbyte- 
rian Hospital.  Booth4  found  23  cases  out  of  2612  performed  at  the 
Roosevelt  Hospital;  Bancroft5  discovered  15  cases  out  of  1413  op- 
erations performed  at  the  New  York  City  Hospital;  and  Derby6  col- 
lected 11  cases  out  of  3120  operations  performed  at  the  St.  Luke's 
Hospital,  all  in  Xew  York  City.  The  percentage  is  therefore  very 
small,  ranging  from  .04  per  cent  reported  by  Beckman,  to  2.2  per 
cent  reported  by  Whipple. 

The  figures  are  indeed  low,  and  probably  do  not  present  the  true 
incidence  of  the  condition,  since  it  is  to  be  remembered  that  the  opera- 
tions were  performed  under  ideal  conditions. 

Whipple  after  making  careful  clinical,  as  well  as  bacteriologic  ob- 
servations, concluded  that  the  cases  of  pneumonia  should  be  divided 


2/4  AFTER-TREATMEXT   OF    SURGICAL   PATIENTS 

into  three  groups:  Group  I  contains  those  patients  who  were  in  a 
good  physical  condition  before  the  operation,  and  in  whom  the  disease 
developed  from  the  first  to  the  fourth  postoperative  day.  lie  found 
that  79  per  cent  of  the  cases  fell  into  this  group. 

Group  II  is  made  up  of  patients  who  came  to  operation  with  pneu- 
mococcus  infection  in  other  parts  of  the  body,  excluding  the  lungs. 
This  group  claimed  7  per  cent  of  his  cases. 

Group  III  included  those  patients  who  developed  pneumonia  (a) 
as  a  terminal  complication;  (b)  in  the  presence  of  other  severe  in- 
fections, (c)  or  in  the  feebler  senile  patients  in  whom  this  disease 
appeared  in  the  late  days  of  the  surgical  convalescence. 

It  has  been  generally  conceded  that  bronchopneumonia  is  most 
often  the  type  which  is  seen  in  these  cases.  Beckman,  however, 
showed  that  15  of  his  eases  were  lobar  pneumonia.  Derby  stated  <S 
of  his  cases  presented  signs  of  lobar  pneumonia.  This  was  also  true 
in  Booth's  eases.  Whipple  was  inclined  to  believe  that  a  majority  of 
his  cases  were  lobar  pneumonia. 

The  signs  and  symptoms  in  these  cases  were  atypical  of  frank  lobar 
pneumonia,  and  there  was  a  tendency  for  the  disease  to  end  by  lysis. 
The  condition  has  been  seriously  considered  by  Bancroft  to  be  due 
to  multiple  infarcts.  Beckman  also  concedes  that  he  '•believes  septic 
emboli  cause  many  of  these  conditions." 

Whipple  explains  that  the  diagnosis  of  lobar  pneumonia  was  made 
by  the  x-ray.  A  systematic  radiographic  examination  of  every  patient 
showing  a  rise  in  temperature,  with  more  or  less  cough  with  suspicious 
blood  findings,  revealed  many  cases  of  this  disease  which  would  ordi- 
narily have  been  overlooked.  By  this  means,  beginning  consolidations 
of  the  lungs  were  noted  even  before  the  physical  signs  appeared. 

In  other  cases  the  x-ray  confirmed  definite  physical  findings,  after 
the  temperature  had  dropped  to  normal. 

The  atypical  symptoms  and  absence  of  complications  are  also  ex- 
plained by  Whipple.  He  states  that  bacteriologie  examinations  of 
the  sputum,  by  culture  and  mouse  inoculations,  revealed  the  pneumo- 
coccus  in  77  per  cent  of  the  eases.  The  type  of  organism,  however, 
was  of  the  least  virulent  group,  as  classified  by  Docbez  and  Avery  of 
the  Kockefellcr  Institute. 

This  type  of  the  pneumococcus  is  found  in  the  throats  of  normal 
individuals  who  have  not  been  in  contact  with  pneumonia  patients 
and  who  have  not  undergone  any  operation. 

The  malady  occurred  in  30  males,  and  \'l  females  of  the  cases  re- 
ported by  Whipple.  Thirty-seven  of  this  number  were  adults.  In 
the  collection  of  the  other  cases,  where  the  ratio  of  sex  is  revealed, 


POSTOPERATIVE   PNEUMONIA  275 

the  percentage  of  male  to  female  compares  favorably  with  "Whipple's 
figures. 

The  age  embraces  patients  from  two  to  seventy  years  old. 

Operations  on  the  appendix,  stomach,  and  gall  bladder  were  about 
equally  divided  as  to  the  frequency  of  occurrence.  Acute  appendicitis, 
with  or  without  pus,  was  more  frequently  followed  by  pneumonia 
than  any  other  operation.  It  is  generally  conceded  that  pus  cases 
are  more  likely  to  develop  this  disease  than  clean  cases. 

Pelvic  operations  do  not  particularly  predispose  to  pneumonia. 
Probably,  this  is  due  to  the  Trendelenburg  position  on  the  operating 
table,  which  allows  the  air  passages  to  drain  thoroughly  during  the 
operation.  Therefore,  the  lessened  number  of  cases  of  postoperative 
pneumonia  appearing  in  women  may  be  attributed  to  this  fact. 

The  winter  season  has  particularly  been  found  to  be  conducive  to 
this  infection,  although  Bancroft  stated  that  the  time  of  year  had  no 
effect  on  the  frequency  of  occurrence  in  his  cases. 

The  predisposing  factors  are  varied.  Sajous7  notes  that  it  is 
favored  by  a  protracted  anesthesia,  preexisting  coryza,  bronchitis  or 
some  chronic  pulmonary  congestion,  general  weakness,  and  the  in- 
halation of  irritating  substances.  To  these  may  be  added,  old  age, 
chronic  infections  in  the  mouth  or  upper  respiratory  passages,  pus 
cases,  and  high  abdominal  operations. 

Ether  in  itself,  as  a  predisposing  factor,  has  been  studied  by  Chap- 
man.8 He  finds  that  by  injecting  this  substance  into  rabbits'  lungs, 
rales  appear  at  once,  the  temperature  rises,  the  respiration  increases, 
the  nostrils  dilate,  and  the  animal  presents  the  characteristic  appear- 
ance of  air  hunger.  After  a  few  hours,  it  dies.  Examination  of  the 
lungs  reveals  at  the  site  of  injection,  "hemorrhagic  tissue,  which  is 
solid,  of  a  dark  red  color,  and  sinks  in  water.  The  stained  sections 
show  absolute  dissemination  of  the  normal  lung  tissue.  The  whole 
inflammatory  area  presents  a  mass  of  red  blood  corpuscles,  white 
blood  cells  and  cells  from  the  alveolar  walls.  Farther  out,  the  lung 
tissue  can  be  recognized.  The  lung  also  shows  the  alveoli  filled  with 
hemorrhagic  exudate,  and  broken  down  cells  of  the  lung  tissue. 

' '  If  the  rabbit  is  etherized  in  the  usual  way,  and  the  narcosis  is  con- 
tinued about  30  minutes  until  rales  appear,  the  bronchial  tissues  be- 
come congested  and  the  alveoli  filled  with  corpuscles.  These  on  macro- 
scopic examination  appear  as  small  hemorrhagic  areas.  Repeated 
etherizations  will  decrease  the  time  of  the  appearance  of  the  rales, 
and  increase  the  amount  of  hemorrhage  into  the  lung  tissue.  Crowd- 
ing the  ether  will  also  tend  to  hasten  the  condition." 


L'(<)  APTER-TREATMENT    OF    SURGICAL    PATIENTS 

It  lias  been  shown  thai  the  lungs  of  healthy  animals  do  not  contain 
bacteria.  After  etherization,  however,  any  number  of  microorganisms 
may  be  found.  So  also  a  culture  of  pneumococci  injected  into  the 
Lungs  of  healthy  animals  will  not  produce  pneumonia,  though  death 
may  be  caused  by  the  resulting  abscesses.  On  the  other  hand,  if  an 
animal  is  permitted  to  inhale  pneumococci.  following  etherization, 
all  the  feature^,  seen  after  prolonged  ether  narcosis  are  noted,  but  in 
addition,  are  very  much  intensified.  <  hapman,  after  his  experiments. 
then,  concluded  that  ether,  in  producing  small  hemorrhages  in  the 
Lungs  due  to  its  irritant  action,  caused  a  most  suitable  soil  for  the 
growth  and  development  of  bacteria,  which  normally  the  lung  tissue 
would  not  tolerate.  Unfortunately,  the  patient  is  further  exposed  to 
pneumonia  from  mucus  or  infection-  particles  from  vomitus  sucked 
into  the  air  passages  incident  to  anesthesia. 

Another  predisposing  factor  which  musl  be  considered  is  the  ex- 
posure  of  the  body  surface,  which  necessarily  occurs  during  the  prepa- 
ration of  the  patient  for  an  operation,  ('old.  cleaning  solutions,  wet 
clothes  coming  in  contact  with  the  patient's  skin  and  particularly  a 
perspiring  patient  exposed  to  a  cold  corridor  immediately  after  his 
stay  in  a   hot   operating  room,  are  important  predisposing  factors. 

In  this  connection,  the  practice  of  nearly  every  hospital,  of  abso- 
lutely ignoring  the  former  habits  of  surgical  patients,  is  undoubtedly 
followed,  ai  times,  by  serious  consequences.  Regardless  of  how  the 
patient  is  accustomed  to  clothing  himself  for  bed,  he  is  usually  given 
a  tub  hath,  a  nightgown  of  Lighl  weight,  opening  in  the  hack,  is  placed 
on  him,  and  he  is  put  with  insufficienl  covering,  into  a  strange  and 
sometimes  uncomfortable  bed.  He  siays  here  just  Long  enough  to  gel 
a  general  congestion  of  the  respiratory  passages,  probably  an  acute 
cold  which  has  not  sufficiently  exhibited  itself  to  prevent  him  from  be- 
ing sent  to  the  operating  table,  lie  is  here  exposed  to  a  cold  metal 
support,  which  is  inadequately  covered  to  prevenl  its  deleterious  ef- 
fect by  coming  in  contact  with  his  hare  hack. 

The  microorganisms  found  associated  with  this  disease,  have  com- 
mon morphologic  and  cultural  features,  hut  biologically  are  divided 
into  a  number  of  groups,  each  of  which  causes  specific  reaction  on  the 
part  of  the  tissues.  Those  cases  which  present  the  bronchopneumonic 
type,  in  addition  to  the  pneumoeoccus,  also  include  various  types  of 

streptococci  as  well  as  other  microorganisms,  such  ;is  the  micr ecu- 

catarrhalis.  the  influenza  bacillus  and  various  other  rarer  bacteria. 

The  prognosis  is  almost  uniformly  good  in  pneumonia,  after  clean 
surgical  cases  and  in  patients  in  good  condition  before  the  operation. 
In  the  very  voung  or  the  aged  it   is  universally  had.     Beckman  re- 


POSTOPERATIVE    PNEUMONIA  277 

ported  recoveries  in  all  his  eases.  In  the  cases  presented  by  Risle- 
however,  the  mortality  varied  from  25  per  cent  in  clean  laparotomies 
to  70  per  cent  where  the  abdomen  was  opened  in  the  presence    of  pus. 

The  mortality  from  pneumonia  in  operations  other  than  laparot- 
omies, as  reported  by  this  observer,  was  40  per  cent.  In  Bancroft's 
cases,  which  included  laparotomies,  as  well  as  other  operations,  16.6 
per  cent  died.  In  Booth's  cases  30  per  cent  succumbed.  Those  cases 
which  recovered,  showed  no  further  symptoms  of  the  disease.  It  has 
been  a  notable  fact,  that  in  the  clean  cases,  the  disease  is  much  milder 
in  nature,  and  of  shorter  duration,  than  in  septic  cases. 

Pneumonia  usually  does  not  occur  before  the  third  or  fourth  day 
after  operation.  It  may.  however,  occur  earlier.  In  one  of  Risley's 
cases  which  presented  rales  before  the  operation,  pneumonia  devel- 
oped within  twelve  hours  after  etherization.  Eleven  of  Booth's 
cases  appeared  within  twenty-four  hours,  and  three  of  Bancroft's 
cases  also  had  definite  signs  by  this  time. 

Symptoms. — The  symptoms  are  varied.  The  condition  does  not 
present  a  definite  onset,  and  the  usual  course  of  a  lobar  pneumonia  is 
not  followed  out.  nor  does  the  disease  take  the  course  which  is  usually 
pursued  by  bronchopneumonia.  As  a  rule,  the  onset  is  initiated  by 
some  rise  in  temperature,  slight  quickening  of  the  pulse  and  respira- 
tions. There  may  or  may  not  be  cough,  but  later  this  symptom  ap- 
pears, the  severity  depending  upon  the  extent  of  the  pulmonary  in- 
volvement. The  temperature,  after  remaining  elevated  from  twelve 
hours  to  about  one  week,  falls  by  lysis.  In  many  cases  the  signs  may 
not  be  discovered  until  the  symptoms  have  subsided.  This  fact  has 
been  definitely  shown  to  be  true  by  ""Whipple,  and  others.  Cases  pre- 
senting the  faintest  symptoms  are  now  radiographed,  in  order  to  be- 
gin treatment  early. 

The  symptoms  and  signs  of  pneumonia,  in  general,  are  so  well 
known,  that  to  rehearse  them  here  would  be  superfluous.  The  recital 
of  the  following  ease  history,  in  this  connection.  howeA*er.  may  be  of 
value,  as  well  as  interesting : 

■7.  J.,  male,  forty-five,  operated  for  appendix  abscess.  This  was  drained,  pa- 
tient put  to  bed.  and  peritonitis  treatment  instituted.  Postoperative  course 
uneventful ;  temperature,  pulse,  and  respiration  normal  for  seven  days.  On  the 
eleventh  postoperative  day,  temperature  went  to  99.5 =  .  pulse  80,  and  the  respira- 
tions to  20.  Xo  serious  trouble  was  suspected.  The  following  day,  the  tempera- 
ture was  100.5.°,  pulse  83,  respiration  24.  The  man  felt  well,  complained  of  no 
pain,  and  general  condition  was  apparently  normal,  with  indefinite  lung  findings. 
One  day  later,  patient  noted  a  very  sharp  pain  on  breathing  and  complained 
of  nausea.  The  temperature  was  now  101.8°,  pulse  94,  respiration  28.  Definite 
signs  of  pneumonia,  lobar  in  typo,  in  the  right  lower  lung  were  discerned.  Dry 
cupping  (Fig.  41)  was  instantly  instituted,  and  from  the  first  application,  the 
temperature  dropped  to  normal.     The  pulse  gradually  fell,  and  after  two  days  was 


278  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

72.  The  respirations  fell  to  18  after  three  days.  The  patient  had  no  more  pain 
or  discomfort  of  any  kind.  The  cupping  -was  kept  up  twice  daily  for  three  days, 
at  the  end  of  which  time,  all  rales  and  other  lung  signs  had  disappeared. 

Treatment. — The  treatment  first  consists  in  systematic  preventive 
measures  being  executed  in  patients  who  enter  hospitals  for  operation. 
The  tub  bath  of  tepid  water  is  desirable  and  the  replacement  of  all 
underwear  with  the  nightgown,  is  to  he  hailed  with  delight,  but  I 
would  certainly  advise  gowns  which  are  opened  in  front,  and  some, 
at  least,  made  of  heavier  material,  to  accommodate  those  patients  not 
used  to  removing  the  underwear  on  retiring.  Xo  patient  should  be 
allowed  to  become  chilled.  The  teeth  should  be  scrubbed  at  least 
three  times  a  day,  with  a  toothbrush  and  this  followed  by  a  thorough 
washing  with  Dobell's  solution,  or  some  other  alkaline  mouth  wash. 
The  lungs  should  be  carefully  examined  and  patients  with  coryza  or 
bronchitis  should  not  be  operated  until  the  condition  has  subsided. 
In  such  eases  or  in  other  lung  complications,  the  operation  may  be 
done  under  local  anesthesia.  If  ether  must  be  used,  give  as  little  as 
possible,  and  at  the  same  time  overlook  no  opportunity  to  drain  the 
air  passages  of  the  excessive  secretions  excited  by  the  anesthetic  even 
if  the  Trendelenburg  position  may  be  used  to  accomplish  this  end. 

At  the  close  of  the  operation  the  patient  is  wrapped  in  blankets,  the 
head,  but  not  the  nose  or  mouth,  protected,  and  is  sent  to  a  bed,  pre- 
viously warmed  with  hot-water  bottles.  It  is  a  notable  fact,  that 
pneumonia  occurs  more  frequently  in  those  patients  who  are  wheeled 
through  long  corridors  to  their  rooms.  The  recovery  room  in  hospitals 
through  elimination  of  this  exposure  has  materially  cut  down  the  in- 
cidence of  the  disease. 

As  soon  as  the  operation  is  ended  the  wet  gown  is  removed,  the 
body  is  rapidly  dried  and  clothed  in  a  dry  warm  gown.  Fresh  air,  a 
room  temperature  of  68°,  and  comfortable  body  warmth  is  now 
maintained. 

The  patient  is  placed  in  a  position  which  will  allow  free  drainage 
of  the  nose  and  mouth,  and  upon  awakening,  is  permitted  to  assume 
any  position  most  comfortable  to  him.  Aged  patients,  particularly, 
are  put  into  a  wheel  chair  a  day  or  so  after  operation,  and  all  patients 
are  encouraged  to  move  around  in  bed.  As  soon  as  possible  they  are 
allowed  to  get  up. 

Following  operations  in  the  upper  abdomen,  especially  gall  bladder 
operations,  as  high  a  position  in  bed  as  can  be  maintained  is  encour- 
aged. In  these  cases,  particularly,  the  hums  arc  likely  to  become  in- 
flamed due  to  the  handling  of  the  high  peritoneum  and  diaphragm. 
In  addition  to  the  regular  orders  for  all  operative  patients  to  take 


POSTOPERATIVE   PNEUMONIA  279 

frequent  deep  breaths,  these  patients  are  assisted  by  an  apparatus 
which  was  devised  by  Bartlett  and  myself  (Fig.  280,  page  741). 
It  consists  of  an  ordinary  mercury  blood  pressure  apparatus,  which 
is  connected  by  a  series  of  rubber  tubes,  to  a  rubber  bag.  The 
patient,  on  bloving  at  the  mouthpiece,  which  is  connected  to  the 
rubber  tubing,  is  enabled  to  register  his  pulmonary  strength  on 
the  scale  of  the  blood  pressure  machine.  In  attempting  to  increase 
his  capacity,  deeper  and  deeper  breaths  will  be  taken,  until  finally 
all  pain  will  disappear  from  the  affected  side.  In  many  in- 
stances patients  are  not  able  to  raise  the  mercury  column  higher  than 
6  mm.  when  they  begin,  but  after  two  days'  effort  they  are  back  to 
normal  again. 

I  have  never  had  a  postoperative  pneumonia  occurring  after  this 
routine  has  been  carried  out.  If  pneumonia  occurs,  the  patient  is  re- 
moved to  a  quiet  room  with  a  southern  exposure.  Sunlight  and  air 
are  freely  admitted  into  the  room,  which  is  kept  at  65°  temperature. 
Absolute  rest  is  enjoined.  Visitors  are  not  permitted,  and  so  far  as 
possible,  the  mind  is  kept  free  of  anxiety,  worry,  or  any  mental  strain. 
The  sponge,  bath  and  alcohol  rubs  are  continued  as  usual,  and  for  high 
temperature,  cool  sponging  is  added.  Application  of  the  ice  bag  to  the 
head  or  affected  side,  or  both,  is  very  beneficial.  After  each  feeding, 
the  mouth  must  be  cleaned  with  4  per  cent  boric  acid  or  Dobell's  so- 
lution of  one-fourth  to  one-half  strength.  For  the  dry  mouth,  a  mix- 
ture of  four  equal  parts  of  albolene9  and  2  per  cent  boric  acid  solution, 
flavored  with  fruit  juice  may  be  applied. 

"Water  is  given  in  abundance  by  mouth.  A  pitcher  of  cool  water  is 
placed  at  the  bedside,  and  at  least  a  glassful  every  hour  is  given.  It 
may  be  necessary  to  give  water  per  rectum,  or  under  the  skin,  but 
under  no  circumstances  should  one  neglect  the  simple  and  continuous 
washing  of  the  system  with  this  medium. 

The  diet  does  not  differ  from  regular  operative  patients,  except  that 
the  patient  is  given  small  frequent  feeding  with  an  increase  of  sodium 
chloride,  in  lobar  pneumonia  cases.  No  distention  of  stomach  or  in- 
testines must  be  tolerated,  as  this  especially  embarrasses  the  heart  ac- 
tion. The  attention  given  the  bowels  and  urinary  bladder,  differs  in 
no  way  from  an  ordinary  laparotomy  case. 

As  soon  as  the  disease  is  discovered,  dry  cupping  on  the  affected 
side  should  be  resorted  to.  I  have  found  this  a  most  excellent  prac- 
tice, and  feel  that  many  cases  of  pneumonia  are  cut  short  by  its  effi- 
cient use.  The  following  disconcerting  explanation  has  been  advanced 
to  explain  the  beneficial  action  of  cupping  in  this  disease:  "Lobar 
pneumonia  is  converted  into  an  exanthematous  fever  by  bringing  the 


280 


AFTER-TREATMENT    OF    SURGICAL   PATIENTS 


bacilli  and  their  attendant  toxins  in  the  blood,  into  the  skin,  and  fixing 
them  with  the  blood  clot,  there  to  stimulate  the  production  of  anti- 
bodies by  the  skin  cells."10 

Cupping  is  carried  out  by  using  special  cups,  designed  for  this  pur- 
pose, or  any  thin  glass,  such  as  a  wine  glass,  jelly  glass,  etc.,  may  be 
used.  The  thinner  the  material,  the  less  apt  are  they  to  pull  off  by 
their  own  weight.  The  principle  involved  is  the  production  of  a  par- 
tial vacuum  in  the  cup,  which  sucks  the  patient's  skin  into  it  and 
causes  the  mottling  d\M'  to  ecchymosis,  which  is  highly  desired. 


Fig.   39.-  Applying  alcohol   to  thi 

In  order  to  produce  the  vacuum,  the  cup  is  swabbed  i  Pig.  39)  out 
with  an  alcohol  sponge.  The  alcohol  is  then  set  afire  I  Pig.  40),  and 
just  before  the  flame  goes  out,  the  cup  is  applied  to  the  body  over  the 
area  of  inflammation  in  the  lung.  The  cups  are  allowed  to  remain 
until  the  skin  becomes  deeply  congested  (Fig.  41)  from  the  negative 
pressure.  At  times  this  may  become  so  greal  as  to  cause  serum  to  ap- 
peal- on  the  surface.  This  is  not  desired,  though  it  does  no  special 
harm. 

One  must  avoid  burning  the  patient.     This  is  prevented  if  the  al- 


POSTOPERATIVE   PNEUMONIA 


281 


cohol  is  applied  smoothly  within  the  cup,  and  the  outer  edge  wiped 
dry  before  it  is  applied.  The  process  is  usually  carried  out  twice 
daily,  and  kept  up  until  there  are  definite  signs  of  improvement. 

As  to  the  medication,  creosote  carbonate  10  to  15  grains11  every  three 
or  four  hours,  given  in  capsules,  has  proved  a  very  good  measure  in 
some  hands.    It  is  warmly  recommended  by  Sajous,  and  also  by  Van 


Fig.   40. — Igniting  the   alcohol. 


Zandt.12  Mathison13  would  use  potassium  iodide  in  addition  to  the 
creosote.  He  states  that  the  antiseptic  action  of  the  creosote  limits 
the  extension  of  the  process,  and  the  iodide  loosens  the  exudate.  Both 
drugs  tend  to  quiet  the  heart  and  both  have  a  diuretic  action. 

The  heart  is  further  supported  by  giving  digitalein  or  tr.  digitalis, 
8  to  10  minims,  every  three  or  four  hours.     If  there  is  excessive  pul- 


282 


AFTER-TREATMENT    OF    SURGICAL   TATIEXTS 


monary  pressure,  tr.  belladonna,  5  to  8  minims,  also  may  be  given  with 
the  digitalis.  If  there  is  any  disease  which  hinders  free  conductivity 
of  the  auricular  impulse  to  the  ventricles,  digitalis  should  not  he  given, 
but  other  stimulants,  such  at  pituitrin,  caffeine,  camphorated  oil  or 
strychnine  may  be  given. 

The  cough  of  pneumonia  may  be  due  to  the  bronchitis  or  to  pleurisy. 
If  the  cupping  does  not  relieve  the  condition  with  its  associated  pain, 


Fig.  41. — Three  cups  in  place.     The  fourth  is  being  slapped  on  just  before  the  fire  completely 

disappears. 

codeine  sulphate,  in  small  .Ins,..  (%  to  l/2  grains)  repeated  often, 
should  be  administered.  Morphine  may  be  necessary  to  relieve  the 
pain. 

For  further  treatment,  the  reader  is  referred  to  works  on  medicine. 

Pulmonary  complications,  other  than  actual  pneumonia  are  fre- 
quently observed  in  postoperative  patients.  Acute  bronchitis,  with 
or  without  an  associated  congestion  of  the  lungs,  is  by  Ear  the  most 


POSTOPERATIVE   PNEUMONIA  283 

frequent  complication  seen  in  the  respiratory  tract  after  surgical  pro- 
cedures. This  condition  is  most  likely  to  occur  in  patients  who  have 
had  subacute  colds  before  the  operation,  or  in  patients  suffering  with 
chronic  bronchitis,  or  some  other  chronic  affection  of  the  lungs.  The 
temperature  may  not  be  very  high,  though  in  some  cases  it  rises  to 
103°  F.  or  more. 

Associated  with  the  excessive  amount  of  mucus  or  mucopurulent 
material  which  is  expectorated,  there  is  increased  respiration,  fast 
pulse,  and  general  evidences  of  serious  illness.  The  severe  symptoms 
usually  disappear  with  seventy-two  hours,  although  the  cough  re- 
mains for  a  number  of  days.  In  cases  where  acute  congestion  of  the 
air  passages  occurs  without  a  prolongation  of  the  cough,  the  tempera- 
ture is  not  so  high  or  the  symptoms  so  marked  as  in  the  bronchitis 
cases. 

Pulmonary  edema  has  never  occurred  in  any  of  my  cases,  though 
it  has  been  reported  by  others.14  The  condition  is  due  to  escape  of 
'serum  through  the  vascular  walls  into  the  alveolar  wall  and  the  al- 
veoli.13 It  is  associated  with  pulmonary  congestion,  and  appears 
most  often  bilaterally.  The  malady  occurs  suddenly,  more  fre- 
quently in  patients  already  suffering  with  Bright 's  disease,16  and 
often  proves  fatal. 

The  chief  symptoms  are  extreme  dyspnea,  cyanosis,  cough,  expec- 
toration of  frothy  seromucous  fluid  and  profound  prostration.  The 
patient  usually  dies  of  heart  failure  and  carbon  dioxide  poisoning. 
Those  who  recover  usually  do  so  suddenly.17 

The  treatment  of  bronchitis  is  the  same  as  outlined  for  pneumonia. 
In  addition.  I  usually  subject  the  patient  to  steam.  This  is  adminis- 
tered by  utilizing  a  specially  devised  croup  kettle,  in  the  nozzle  of 
which  a  little  cotton,  moistened  with  tincture  of  benzoin,  is  placed, 
and  the  medicated  steam  is  inhaled  by  the  patient.  In  order  to  get 
the  full  benefit  of  the  steam,  a  cone  is  made  of  paper  and  this  ar- 
ranged over  the  nozzle  of  the  kettle ;  the  patient  then  places  his  nose 
and  mouth  in  the  largest  end  of  the  paper  cone  and  inhales  the  steam. 
Expectorants,  such  as  syrup  of  white  pine,  teaspoonful  every  three 
hours,  or  ammonium  chloride,  three  to  five  grains  every  three  hours 
may  be  employed.  For  the  congestion  of  the  lungs  we  have  never 
found  any  remedy  which  surpasses  cupping.  This  is  used  in  connec- 
tion with  regular  treatment  for  bronchitis. 

Pulmonary  edema  requires  quick  and  efficient  measures.  Artificial 
respiration  is  probably  most  effective  in  tiding  the  patient  over  an 
acute  attack.  Cases  are  reported155  where  this  measure  alone  has  saved 
patients  from  an  untimely  death.  If  the  blood  pressure  is  high,  vene- 
section, with  the  escape  of  500  c.c.  of  blood  is  advised.    Atropine  sul- 


284  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

phate,  1/100  grain,  and  repeated  in  half-hour  or  hour  intervals,  until 
the  physiologic  effect  is  produced,  may  prove  of  value.  The  patient 
is  changed  frequently  to  prevent  hypostatic  congestion,  and  the  heart 
action  supported  by  digalein,  caffeine,  pituitrin  or  strophanthus. 

Pleurisy 

Pleurisy  is  occasionally  seen  in  postoperative  patients.  In  our  ex- 
perience, it  occurs  mosl  frequently  after  high  abdominal  operations, 
particularly  those  associated  with  peritonitis.  Bibergeil,19  in  1905, 
found  16  cases  of  pleurisy  with  effusion,  out  of  3909  abdominal  opera- 
tions. Burnham,20  in  1!U4.  found  dry  pleurisy  occurring  45  times, 
and  pleurisy  with  effusion  14  time,  in  13,013  operations. 

Symptoms. — The  symptoms  of  pleurisy  are  initiated  by  severe 
pain  on  the  affected  side,  which  is  particularly  excruciating  when  the 
patient  takes  a  breath.  It  usually  precedes  the  temperature  a  day  or 
so.  The  affection  is  more  common  on  the  righl  side.  Diaphragmatic 
pleurisy  is  probably  x<-ry  commonly  associated  with  involvement  of 
the  base  of  the  lung.21  This  in  itself  produces  painful  deglutition  and 
breathing,  which  forces  the  patient  to  use  the  upper  thorax  during 
respiral  ion. 

The  signs  of  dry  pleurisy  are  chiefly  the  friction  rub,  which  may 
be  heard  directly  over  the  lesion.  This  being  absent,  the  condition 
may  be  mistaken  for  pleurodynia  or  costal  neuralgia.  The  presence 
of  fever  eliminates  these  conditions.  Where  effusion  is  present,  (h1- 
pending  upon  the  amount,  of  course,  the  chesl  movements  are  limited. 
there  is  dullness,  absence  of  tactile  fremitus  and  vocal  resonance. 
weakness  or  absence  of  the  respiratory  sounds  and  the  heart  may  be 
displaced  to  the  opposite  side  of  the  effusion.  In  such  effusions. 
Grocci,  in  1902,  described  a  paravertebral  triangular  area  of  dullness 
on  the  side  opposite  that  of  the  effusion.  This  sign  is  present  in  prac- 
tically every  case.  The  x-ray22  may  he  used  to  good  advantage  in 
clearing  up  the  diagnosis.  Exploration  of  the  chest,  with  an  aspirat- 
ing needle,  should  he  done  in  all  cases  presenting  the  above  signs,  and 
the  fluid  obtained  should  he  carefully  examined  for  pus  cells  and  bac- 
teria. 

Tic-  leucocyte  count,  in  eases  with  serous  effusion  in  Burnham's 
eases,  was  around  thirteen  thousand.  Morse23  states  that  if  there  is 
a  continuous  leucocytosis  in  these  c,-ises,  there  is  certainly  some 
complication  elsew  here. 

Treatment. — The  treatmenl  is  expectant.  Dry  cupping  is  indeed 
a  g 1  remedy  for  this  condition.     <  'ases  of  dry  pleurisy  are  at  once 


POSTOPERATIVE   PNEUMONIA  285 

cut  short.  Where  serous  effusion  occurs,  however,  frequent  aspira- 
tions, in  addition  to  the  cupping,  is  advised.  In  doing  the  paracen- 
tesis, in  addition  to  aseptic  care,  one  must  bear  in  mind,  that  syncope 
and  even  death,  has  followed  this  simple  procedure.  Some  would 
give  a  mild  stimulant  such  as  an  ounce  of  whiskey.  All  the  fluid 
should  not  be  withdrawn  at  one  time.  It  is  necessary  to  remove  only 
that  amount  which  will  remove  all  symptoms. 

The  results  following  a  failure  to  observe  this  rule  are  at  times 
albuminous  expectoration,  cough,  or  even  edema  of  the  lungs  may  oc- 
cur. I,  therefore,  have  my  patients  in  bed,  when  this  procedure  is 
necessary,  as  advised  by  Forehheimeiv4  and  on  the  first  appearance 
of  faintness,  severe  cough,  or  feeling  tight  around  the  waist,  the 
operation  is  at  once  stopped. 

The  patient  will  lie  on  the  affected  side,  and  there  is  no  objection 
to  this  position,  but  he  must  continue  to  practice  deep  respiration. 
The  affected  side  may  be  immobilized  with  adhesive  strips,  the  first 
being  applied,  however,  at  the  end  of  expiration.  All  patients  with 
any  pulmonary  complications,  should  be  removed  to  the  rooms  set 
apart  for  pneumonia,  where  fresh  air  and  sunlight  may  be  had  in 
abundance. 

Empyema  may  follow  a  pleural  effusion,  or  it  may  occur  as  a  di- 
rect complication.  Bibergeil  found  fourteen  in  the  cases  analyzed 
by  him,  and  Burnham  found  six.  Beckman  found  three  in  his  series 
of  cases.  This  condition  most  often  occurs  after  operations  for  per- 
forated gastric  or  duodenal  ulcer,  or  suppurative  appendicitis,  as- 
sociated with  a  peritonitis,  either  local  or  general.  In  a  majority  of 
the  cases,  subphrenic  abscess  also  is  found,  and  this  malady  appar- 
ently has  a  definite  relation  to  empyema,  or  the  pleural  affection 
may  be  the  cause  of  the  abscess  in  the  abdomen.  In  our  experience, 
we  can  heartily  agree  with  Gee  and  Harder,23  that  '"Pleuritic  effu- 
sion, following  abdominal  infections  is  more  often  purulent  than 
serous." 

The  symptoms  are  more  or  less  general.  The  temperature  after 
the  operation  may  fall  to  normal,  only  to  rise  again — slowly,  however, 
as  the  disease  becomes  more  and  more  severe.  It  often  reaches  101°. 
It  may  remain  high,  with  remissions,  until  just  before  death,  when 
it  falls  to  subnormal.  In  some  cases,  a  hyperpyrexia  occurs  at  this 
time,  the  temperature  going  to  107c  or  108°.  There  are  chills  and 
chilly  sensations  preceding  the  rise  in  temperature  at  times,  which  are 
followed  by  sweats.  The  pain  and  general  physical  signs  are  about 
the  same  as  seen  in  pleurisy  with  effusion.  The  most  important  point 
in  diagnosis  is  the  examination  of  the  aspirated  fluid. 


286  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

The  fluid  may  be  purulent  from  the  start,  but  it  is  usually  reddish 
or  yellowish  in  color,  and  turbid.  Burnham  feels  that  turbid  exu- 
dates will  soon  pass  into  pus  exudates,  while  a  clear  sterile  fluid  is 
most  likely  to  resort)  without  pus  formation. 

The  prognosis  is  had.  In  all  of  Burnham 's  cases  the  patients  died. 
It  is  extremely  fatal  in  very  young  patients,  and  in  the  aged.  For- 
tunately the  disease  most  often  occurs  in  middle-aged  adults,  hut 
even  among  these  a  large  percentage  of  postoperative  empyema 
cases  die. 

Empyema  is  further  discussed  <>u  pages  2!)4  and  732. 

Bibliography 

iBeckman:     Surg.,  Gynec.  ami  Obst.,  1914,  x\iii.  553. 

-Rislcy:     Boston  Med.  and  Surg.  Jour.,   1910,  clxii,  77 

3WMpple:     Med.  Bee,  New  York,  1916,  lxxxix.  581. 

tBooth:      Ibid.,  582. 
Bancroft:     Ibid.,  583. 

6Derby:     Ibid.,  582. 

"Snjous:     Analytic  Cyclopedia  Practical  Medicine,  191<>,  vii,  .">•".."). 

^Chapman:     Ann.  Surg.,  1904,  p.  700. 

9Meara:     The  Treatmenl   of  Acute   [nfectious  Diseases,  1916,  p.  63. 
loEyermann:     Personal  communication. 
^Thompson:     Med.  Rec,  New  York,  April,  1911. 
i2"Van  Zandt:     Texas  State  Jour.  Med.,  December,  1912. 
isMathison:     Brit.  Med.  Jour.,  November,  1910. 
wNauwerck:     Deutsch.  Med.  Wchnschr.,   1895,  xxi,   L21. 
i  s.-ijniis:     Analytic  Cyclopedia  Practical  Medicine,  1916,  \i.   153. 
i6Robin:     Med.  Press  and  Circ,  February,  1912. 
nBiesman:     Quoted  by  Sajous. 

isKulenkamp:     Deutsch.  Med.  Wchnschr.,  August,  1909. 
L9Bibergeil:     Arch.  J',  klin.  Chir.,  1905,  Ixxviii,  339. 
-"Burnham:     Surg.,  Gynec.  and  Obst.,   1914,  xix,  468. 
ziDexter:     Cleveland  Med.  Jour.,  February,  191  t. 
22Englebach  arid  Carman:     Am.  Jour.  Med.  Sc,  December,  1911. 
23Morse:      Boston    Med.   and    Surg.   Jour.,   December,   1900. 
24Forchheimer :     Jour.  Am.  Med.  Assn.,  January,  1907. 

•  Gee  and  Harder:     Albutt  and    Rolleston's  System  of  Medicine,   1910,  v,  535. 
The  following  was  also  consulted: 

Emerson:      Arch.  Int.  Med.,  May.  1909. 


CHAPTER  XXXV 

PAROTITIS 
By  0.  F.  McKittrick,  St.  Louis..  Mo. 

Inflammation  of  the  salivary  glands,  particularly  the  parotid, 
occurs  occasionally  after  operative  procedures,  especially  those  in- 
volving the  pelvic  organs.  The  complication,  as  a  rule,  is  of  very 
serious  import,  one  demanding  instant  attention  regardless  of  the 
fact  that  it  may  at  first  appear  innocent  and  apparently  occasion- 
ing no  alarm. 

The  literature  on  postoperative  parotitis  is  limited,  few  men  hav- 
ing considered  the  subject  worthy  of  the  study  it  most  certainly 
deserves.  Fowler1  stated  that  he  had  seen  it  occur  eight  times  in 
patients  after  undergoing  laparotomies.  Four  of  these  cases  were 
observed  after  operations  upon  the  adnexa,  one  after  operative  inter- 
ference for  extrauterine  pregnancy  and  two  after  operations 
for  appendicitis.  "We  have  seen  this  complication  develop  five 
times.  Twice  in  patients  operated  for  appendicitis,  one  being  a 
most  violent  suppurative  case.  Once  after  intestinal  suture  (ileal) 
and  abdominal  drainage  three  days,  following  a  kick  in  the  abdo- 
men by  a  horse,  once  after  removing  a  single  pyosalpinx. during  the 
course  of  a  general  puerperal  septicemia.  The  last  case  to  develop 
a  parotitis  Avas  a  cancer  of  the  rectum  in  which  an  anterior  left- 
sided  colostomy  was  done.  At  the  same  time  a  Kraske  was  per- 
formed. 

Blair2  has  treated  this  condition  in  three  postoperative  cases. 
One  occurred  after  operation  for  suppurative  appendicitis  and  two 
others  following  operative  procedures  for  inflammatory  pelvic  dis- 
turbances. 

This  disease  occurring  in  patients  other  than  those  convalescing 
from  surgical  procedures  does  not  concern  us  here.  However,  it 
is  so  freqnenty  associated  with  the  infectious  diseases  such  as  typhoid 
fever,  cholera,  typhus,  scarlet  fever,  pneumonia,  erysipelas,  dys- 
entery, etc.,  and  other  infectious  conditions  such  as  septicemia  or 
pyemia  that  it  is  not  surprising  that  it  should  occur  so  frequently 
in  the  cases  presenting  some  abdominal  inflammation. 

Acute  inflammation  of  the  salivary  glands,  by  far  most  commonly 
noted  in  the  parotid,  is  due  to  infections  either  metastatic  in  na- 

287 


2SS  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

ture  or  ascending  up  the  excretory  ducts.  Any  infectious  process 
such  as  mentioned  above  may  be  an  inciting  factor.  Local  condi- 
tions within  the  mouth  certainly  add  to  the  predisposition  for  in- 
fection. During  any  operation  performed  under  a  general  anes- 
thetic the  salivary  secretions  decrease  in  amount  following  the 
firsl  stimulating  influences.  For  the  first  few  days  the  patient  is 
given  a  liquid  diet  which  neither  entails  actual  use  of  the  jaws 
nor  stimulation  of  the  salivary  secretions.  As  a  result  the  inac- 
tive glands,  whose  resistance  has  already  been  lowered  by  the  opera- 
tive procedure,  invite  invasion  from  the  myriads  of  microorgan- 
isms retained  in  the  mouth.  Their  entry  through  the  excretory 
ducts  is  soon  followed  by  mosl  active  proliferation  within  the 
substance  of  the  gland  which  furnishes  an  excellent  soil  for  growth 
and  development.  Direct  trauma  from  ulcerated  teeth  or  manipula- 
tion by  the  anesthetist  may  occasionally  be  followed  by  this  condi- 
tion. 

In  this  connection  trauma  of  the  abdominal  viscera,  of  the  tes- 
ticle or  ovary  or  of  the  other  pelvic  organs,  has  occasioned  a  paro- 
titis. CrandalP  stales  thai  it  has  been  observed  in  facial  paralysis, 
neuritis,  diabetes,  and  even  from  poisoning  due  to  mercury,  to  lead, 
or  to  the  iodides,  It  has  also  occurred  in  the  course  of  rectal  feed- 
ing, a  matter  which  deserves  attention.4 

Crandon5  notes  that  ''it  may  follow  any  injury  or  disease,  but  it 
is  more  frequent  after  injuries  and  operations  on  the  pelvic  organs 
than  after  diseases  in  any  other  part  of  the  body." 

Prom  the  experiences  "(  others  parotitis  in  the  surgical  conva- 
lescent appears  more  frequently  in  women.'1  All  of  Fowler's  cases 
and  two  of  Blair's  were  of  this  sex.  (if  my  own.  however,  only 
two  were  women. 

Rhodes7  has  recently  reviewed  the  literature  of  subacute  and 
chronic  inflammations  of  the  salivary  glands,  not  postoperative. 
His  findings  in  Hie  forty  cases  reported,  seemingly  do  not  bear  out 
the  general  opinion  thai  the  female  is  more  liable  to  the  disease 
than  the  male.  Probably  the  fad  that  more  w n  undergo  opera- 
tions than   men  accounts   for  the  apparenl    discrepancy. 

Rhodes  stales  that  "the  condition,  if  not  bilateral  from  the  start, 
tends  to  become  so,"  but  more  than  one  pair  of  the  glands  were  not 
involved  except  in  two  of  the  cases  reviewed  by  him.  In  these  he 
noted  that  all  the  salivary  glands  were  affected.  He  also  found 
that  the  parotid  glands  were  involved  in  56.4  per  cent,  the  submax- 
illary glands  in  30.7  per  cent,  tin'  sublingual  glands,  7.(i  ])er  cent, 
and  all  the  "lands  in  5.3  per  cent   of  the  cases  reported. 


PAROTITIS  289 

The  course  of  this  disease  is  about  one  week  in  postoperative 
eases,  but  unless  treatment  is  instituted,  the  disease  remains  longer 
and  always  tends  to  progress,  though  a  few  instances  have  spon- 
taneously subsided.  It  is  not  advisable,  however,  to  await  such  a 
favorable  outcome,  but  the  worst  should  be  expected  and  prepared 
for  in  every  case.  Rhodes  states,  concerning  the  subacute  and 
chronic  types  that  "there  is  apparently  no  tendency  to  abscess  for- 
mation. In  fact  abscess  formation  would  appear  to  be  confined  to 
cases  of  obstruction  by  stone  and  metastatic  infection."  Post- 
operative parotitis  being  the  result,  in  the  majority  of  the  cases, 
of  this  latter  condition,  the  complication  mentioned  above  certainly 
is  to  be  expected. 

Symptoms. — The  symptoms  appear  usually  within  three  to  ten 
days  after  the  operation,  though  in  one  of  Fowler's  cases  they  did 
not  appear  until  eighteen  days.  There  occurs  a  rise  in  temperature 
with  an  accompanying  rise  in  pulse  rate  and  in  most  of  the  cases 
the  individual  is  extremely  ill.  The  temperature  continues  to  rise 
until  104  or  105  degrees  is  reached.  Very  soon  a  swelling,  usually 
just  in  front  of  the  lobe  of  the  ear.  is  seen,  since  as  Blair  has  said, 
the  capsule  is  less  dense  here  and  (as  mentioned  before)  the  paro- 
tid gland  is  more  frequently  involved.  Later  the  whole  gland  be- 
comes affected,  causing  the  face  and  cheek  to  swell  and  the  lips 
and  eyelids  to  become  edematous.  In  the  most  severe  cases  the 
swelling  may  be  so  rapid  that  the  edema  quickly  obscures  the  real 
cause  of  the  trouble.  The  skin  may  present  a  shiny  appearance  or 
even  discoloration,  the  whole  picture  being  that  of  an  acute  septic 
process  which  is  localized  in  the  side  of  the  face  and  neck.  The  pain 
from  the  start  is  most  intense  owing  to  the  resistance  the  tense 
capsule  offers  to  the  swelling  gland.  In  the  vast  majority  of  the 
cases  pus  formation  soon  occurs.  An  examination  of  the  parotid 
papilla  reveals  this  region  of  the  mouth  swollen  and  as  Blair  has 
interpreted  it,  the  congested  mucous  membrane  lining  of  the  duct 
may  be  noted  at  the  apex  as  a  dark  red  spot.  Saliva  will  have 
ceased  to  be  excreted  in  many  instances  and  on  gentle  pressure 
pus  may  be  easily  expressed.  In  the  worst  cases  extensive  sup- 
puration takes  place,  the  pus  burrowing  in  every  direction.  Un- 
less liberated  by  early  incision,  the  external  auditory  canal  is  fre- 
quently the  first  to  be  broken  into,  though  invasion  of  the  deep  cer- 
vical and  thoracic  tissues,  the  retropharyngeal  space  and  even  the 
maxillary  joint  may  quickly  occur.  Blair  notes  that  through  the 
olivary  foramen  the  infection  may  enter  the  cranial  cavity.  Throm- 
bosis of  the  veins  here  or  in  other  portions  of  the  body  may  result. 


290  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

In  the  milder  class  of  cases  there  may  be  only  a  localized  swell- 
ing which  disappears  within  a  few  days  or  else  develops  into  a 
localized  abscess  within  the  gland  substance.  In  the  severe  cases, 
however,  the  diffuse  suppuration  which  is  almost  always  seen  in 
those  patients  with  poor  resistance  and  otherwise  debilitated,  is 
simply  in  many  instances,  the  beginning  of  the  end,  and  the  most 
extensive  measures  employed  in  combating  the  difficulty  can  only 
be  palliative.  The  prognosis  depends  upon  the  condition  of  the  pa- 
tient at  the  beginning  of  the  outset  of  symptoms. 

"When  these  appear  late  in  a  complicated  convalescence  in  a  well 
preserved  patient  even  the  most  severe  infection  does  not  prove  fatal. 
In  those  individuals  already  weakened  by  disease,  debilitated  and 
presenting  some  suppurative  condition  in  the  abdominal  cavity  the 
prognosis  is  extremely  grave  and  unless  thorough  and  prompt  sur- 
gical measures  are  at  once  undertaken  the  patients  almost  always 
die. 

Of  the  eases  reported  by  Fowler,  however,  none  died  and  only 
one  of  the  eases  presented  a  bilateral  infection.  In  my  own  experi- 
ence such  a  fortunate  outcome  was  not  seen.  Two  of  the  patients 
and  the  one  was  the  case  of  ruptured  intestines  following  trauma, 
a  boy  of  sixteen  died  within  four  days  after  the  first  appearance 
of  the  gland  affection  three  days  after  the  operation.  The  other 
was  the  case  of  puerperal  septicemia  in  which  salpingectomy  was 
done  and  the  general  postoperative  course  was  uneventful  until  the 
fifth  day  when  the  temperature  which  had  been  normal  two  days 
shot  up  to  103°  with  attendant  soreness  and  swelling  in  the  region 
of  the  right  parotid  gland  and  neck.  The  patient  rapidly  became 
prostrated  and  within  thirty  six  hours  there  was  marked  fiuctuation 
just  below  the  parotid.  Considerable  pus  was  drained,  but  twelve 
hours  later  the  swelling  not  having  decreased,  but  rather  increased, 
particularly  in  the  parotid  region,  extensive  incisions  were  made  in 
every  direction  and  the  gland  capsule  widely  opened.  In  spite  of 
this  the  patient  succumbed  after  a  few  days  of  intense  suffering 
from  general  septicemia. 

Both  these  cases  presented  only  a  unilateral  parotitis.  The  three 
patients  who  recovered  had  a  bilateral  affection  and  in  each  in- 
stance the  glands  were  widely  drained  after  the  Blair  technic 
within  twelve  hours  after  the  beginning  of  the  infection  in  each  of 
the  parotid  glands  and  the  adjacent  regions.  The  operations  were 
carried  out  under  gas  anesthesia  and  were  quickly  done,  the  wounds 
being  left  wide  open  with  gauze  drainage  only. 

Blair's   postoperative   cases   were   also   less   fortunate   even   than 


PAROTITIS 


291 


ours.  Only  one  of  his  cases  recovered,  the  other  two  dying  of  a 
general  septicemia  despite  the  most  radical  exposure  of  the  in- 
fected regions. 

Treatment. — The  treatment  is  first  and  always  preventive.  It  has 
been  our  custom  to  allow  patients  to  chew  gum,  beginning  the 
first  postoperative  day  and  continuing  to  do  so  until  they  start  to 
take  solid  food.  The  mouth  is  kept  scrupulously  clean  by  washing 
with  some  alkaline  antiseptic  mouth  wash  and  scrubbing  the  teeth 
twice  a  day.  The  patient  is  given  a  bread  crust  or  some  other  solid 
food  to  chew  to  stimulate  the  salivary  secretion  and  other  digestive 
secretions  in  order  to  avoid  this  possible  complication.  Patients 
who  are  prone  to  sleep  with  the  mouth  open  or  those  subject  to 
mouth  breathing,  particularly  when  recumbent,   are  protected  by 


Fig.   42. — Gauze  moistened  in  equal  parts   of  glycerin  and   water  to   prevent  the   open   mouth 

from  drying. 

keeping  six  layers  of  15  x  15  mesh  gauze  (Fig.  42)  moistened  with 
a  solution  of  half  water  and  half  glycerin  over  this  orifice.  Such 
a  maneuver  prevents  the  dryness  of  the  mouth  and  the  attendant 
dangers  occurring  in  these  patients.  If  in  spite  of  these  measures 
infection  occurs  of  the  parotid,  Mtiller's8  suggestion  may  be  tried 
during  the  preliminary  study  of  the  condition.  This  consists  in 
gently  massaging  the  parotid  to  determine  whether  any  pus  ex- 
udes from  Stenson's  duct.  If  this  is  present,  it  is  carefully  ex- 
pressed. If  pus  is  not  obtained  according  to  Mtiller  there  is  no 
reason  to  suspect  metastatic  parotitis  and  massage  must  not  be  en- 


2f)2  AFTER-TREATMENT   OF    SURGICAL    PATIENTS 

tertained.  In  the  meantime  ice  is  applied  directly  over  the  region 
of  the  injection. 

Blair  states  that  "if  suppuration  occurs  it  will  usually  be  on 
the  third  or  fourth  day  and  be  accompanied  by  an  increase  of  all 
symptoms.  This  is  the  proper  time  for  radical  treatment.  If  es- 
pecially tender  or  softened  spots  can  be  found,  these  may  be  opened 
by  an  incision  down  to  the  capsule.  A  round-nosed  conical  artery 
forceps  should  then  be  inserted,  but  in  the  presence  of  severe  symp- 
toms the  surgeon  should  not  wait  for  definite  fluctuation,  which 
owing  to  the  tenseness  of  the  capsule,  may  never  be  evident.  In 
such  cases  radical  treatment  may  be  urgently  necessary  within 
twenty-four  hours  after  the  first  appearance  of  the  symptoms. 
Here  in  the  absence  of  any  local  softening,  an  incision  should  be 
made  just  in  front  of  the  ear  from  the  zygoma  to  the  angle  of  the 
jaw  down  to  the  capsule  and  the  flap  forcefully  drawn  forward 
with  sharp  hooked  retractors.  If  there  is  edema  of  the  neck  the 
incision  may  extend  to  the  clavicle  through  the  deep  cervical  fascia, 
the  trunk  ami  branches  of  the  seventh  nerve  lie  deep  in  the  gland, 
near  its  posterior  part,  and  will  not  be  injured  by  any  carefully 
made  incision. 

"In  this  way.  nearly  the  whole  gland  can  be  exposed.  By  in- 
cisions carefully  made  through  the  capsule,  the  swollen  gland  will 
be  permitted  to  expand,  which  will  increase  its  blood  supply  and 
lessen  the  danger  of  gangrene. 

"If  pus  does  not  come  on  opening  the  capsule,  the  substance  of 
the  gland  can  be  explored  at  various  points  by  inserting  a  round- 
nosed  artery  forceps,  no1  overlooking  the  prolongation  of  the  gland 
that  runs  forward  with  the  first  part  of  the  duct.  If  more  radical 
exposure  of  the  capsule  is  made,  the  latter  should  be  incised  in  a 
number  of  places,  thus  decreasing  the  tension  in  every  part  of  the 
gland.  Failure  to  do  this  in  one  of  the  writer's  cases  made  it  later 
necessary  to  reopen  the  capsule  of  that  part  of  the  gland  that  runs 
forward  with  the  first  part  of  the  duct.  The  operation  requires 
but  a  few  minutes  under  a  gas  anesthesia,  and  the  wound  is  packed 
Avide  open." 

When  the  submaxillary  or  sublingual  glands  are  involved  they 
are  incised  and  allowance  made  for  free  drainage.  The  wound 
later  is  to  be  treated  as  any  other  infection,  and  as  it  begins  to 
granulate,  careful  attention  should  be  given  the  skin  edges  to  keep 
them  approximated  with  adhesive  to  avoid  extensive  scarring.  As 
a  ride  very  little  scar  follows  such  operations  if  the  proper  atten- 
tion has  been  given  the  healing  wound. 


PAROTITIS  293 

Bibliography 

iFowler:  The  Operating  Eoom  and  the  Patient,  Philadelphia,  1913,  W.  B.  Saun- 
ders Co.,  p.  196. 

2Blair:     Med.  and  Surg.,  March,  1917,  p.  34. 

sCrandall:      Sajous'  Analytic  Cyclopedia  of  Practical  Medicine,   1917,  viii,   68. 

4Fenrick:     Brit.  Med.  Jour.,  1909,  i,  3  297. 

sCraudon  and  Ehrenfried:  Surgical  After-treatment,  Philadelphia,  1909,  W. 
B.  Saunders  Co.,  p.  263. 

sPaget:     Lancet,  London,  1SS7,  i,  314. 

7Ehodes:     Lancet-Clinic,  1915,  cxiii,  211. 

sMiiller:     Quoted  lay  Crandall. 


CHAPTER  XXXVI 

SUBDIAPHRAGMATIC  EMPYEMA  (Localized) 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

The  misnomer  subphrenic  abscess  is  an  uncommon  affection,  as 
Jopson1  lias  rightly  stated,  bui  a  perusal  of  the  literature  will 
readily  convince  one  that  it  must  be  reckoned  with.  Localized  col- 
lections of  pus  which  are  situated  immediately  beneath  and  in  eon- 
tact  with  the  diaphragm  are  found  following  operations,  particu- 
larly operations  for  appendicitis. 

The  condition  was  described  as  early  as  1829  by  Wright2  and  one 
year  later  Graves  and  Stokes  reported  a  patient  dying  from  this 
complication.  Barlow  and  Wilks3  in  1845  were  the  first  to  distin- 
guish between  the  signs  referable  to  perforating  gastric  ulcer  and 
pneumothorax.  Later  on  other  cases  were  reported  by  Duehek,4 
Bamberger,5  and  Bernheim.6  Von  Volkmann  in  1879  first  operated 
for  the  condition  and  since  that  time  many  men.  including  Patsch,7 
Taylor."  Fitz9  and  Leydon,10  have  reported  cases,  particularly  fol- 
lowing appendicitis.  Of  late  years  Treves11  has  reported  6,  and 
Ross1'-'  ol  instances  following  appendectomies. 

The  causes  of  this  complication  besides  those  already  mentioned 
are  varied  indeed.  Anything  capable  of  producing  local  peritonitis 
beneath  the  diaphragm  may  give  rise  to  a  subdiaphragmatic  ab- 
scess. Following  appendicitis,  perforations  of  the  stomach  and 
duodenum,  come  liver  abscesses,  suppurative  cholecystitis,  peri- 
nephritis, pancreatitis,  perforation  of  the  colon,  etc.  The  condition 
has  also  followed  tonsillitis,  influenza  and  boils. 

The  mode  of  infection  of  the  subphrenic  spaces  following  disease 
of  the  appendix  especially  has  keen  carefully  worked  out  from  ana- 
tomic, clinical,  and  experimental  standpoints  by  Barnard,13  Lance." 
and  Cosentino,15  respectively.  They  agree  that  it  is  a  pari  of  the 
genera]  peritonitis  (the  cases  of  true  localized  subphrenic  abscesses 
being  excluded).  Infection  may  be  carried  by  the  blood  or  it  may 
occur  by  direct  extension  up  the  lower  peritoneal  fossa  by  lym- 
phatic extension  either  up  the  righl  retroperitoneal  cellular  tissue  or 
up  the  lymphatics  around  the  deep  epigastric  artery  to  the  falci- 
form ligament.  In  rare  instances  the  portal  vein  served  as  the  me- 
dium  through   which   the   infection   occurred.     According  to  Ross 

294 


SUBDIAPHRAGMATIC   EMPYEMA  295 

extension  up  the  peritoneal  fossa  is  by  far  more  common.  Barnard 
has  divided  all  subphrenic  abscesses  according  to  their  location  as 
regards  the  falciform  and  lateral  ligaments.  By  this  arrangement 
he  recognizes  anterior  and  posterior  intraperitoneal  abscesses  on 
each  side  and  right  and  left  extraperitoneal  abscesses. 

A  right  anterior  intraperitoneal  abscess  would  then  be  located 
between  the  upper  surface  of  the  right  lobe  of  the  liver  and  the 
diaphragm.  The  one  posteriorly  would  be  bounded  by  the  liver 
and  gall  bladder  in  front  and  the  abdominal  parietes  behind. 

A  left  anterior  intraperitoneal  abscess  or  splenic  abscess  would 
be  bounded  by  the  diaphragm  above,  the  liver  below  and  to  the 
right,  and  the  spleen  on  the  left.  The  one  posteriorly  would  be 
situated  in  the  lesser  peritoneal  cavity. 

A  right  extraperitoneal  subphrenic  abscess  lies  in  the  space  be- 
tween the  layers  of  the  coronary  and  other  peritoneal  ligaments 
of  the  liver.  The  left  extraperitoneal  abscess  would  have  like 
boundaries  on  the  left  side. 

Others,  however,  feel  this  distinction  is  hardly  necessary  and 
have  excluded  the  extraperitoneal  spaces.  Taking  the  suspensory 
ligament  as  a  dividing  line,  then,  those  abscesses  of  appendiceal, 
hepatic  or  duodenal  origin,  are  located  to  the  right  of  this  liga- 
ment; while  abscesses  arising  as  a  consequence  of  gastric  perfora- 
tion, or  inflammation  of  the  pancreas  or  spleen  are  found  to  the 
left.  The  mesentery  of  the  transverse  colon  prevents  the  downward 
extension  of  the  process  and  the  colon  with  the  omentum  walls  off 
the  abscess  from  the  greater  peritoneal  cavity.  Recently  Judd1G 
has  called  attention  to  the  extraperitoneal  spaces  in  their  relation 
to  pus  from  the  kidneys.  He  states  that  though  it  may  be  difficult 
to  determine  clinically  which  one  of  the  pouches  contain  the  infec- 
tion, a  detailed  knowledge  of  their  boundaries  is  important.  He 
further  adds  that  one  or  more  of  the  spaces  may  be  involved  at 
the  same  time. 

In  the  majority  of  cases  the  abscess  occurs  on  the  right  side.  In 
nearly  all  of  twelve  cases  reported  by  Barnes  and  in  29  of  Ross' 
cases  was  the  location  in  this  region. 

Subdiaphragmatic  abscess  occurs  more  often  in  men  than  women, 
the  time  of  life  being  around  the  third  decade.  It  is  comparatively 
rare  under  14  years  of  age,  occurring  only  once  following  500  con- 
secutive operations  for  appendicitis  reported  by  Ross.  In  3391 
such  consecutive  operations  this  same  author  found  the  condition 
to  occur  in  .8  per  cent  of  the  cases.  On  410  consecutive  autopsies, 
Kelly  and  Hurdon17  found  the  malady  13  times;  in  more  than  50 


296  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

per  cent  of  the  cases  the  affection  was  appendiceal  in  origin.  Lance 
collected  94:5  cases  of  subdiaphragmatic  abscess,  222  of  which  were 
duo  to  acute  appendicitis.  Piquand18  reviewed  890  instances  of  this 
condition  and  recorded  191  as  being  due  to  appendiceal  affection. 
Of  the  cases  reported  by  Judd,  9  were  associated  with  appendecto- 
mies, 7  with  gall  bladder  operations,  7  with  ruptured  duodenum, 
4  with  ruptured  gall  bladder,  2  with  perforating  gastric  ulcers,  1 
with  genera]  peritonitis,  1  with  a  tuberculous  lesion  elsewhere  in 
the  body,  four  with  focal  infections  and  one  following  an  operation 
on  the  stomach. 

The  contents  of  the  abscess  varies  with  the  organ  involved.  The 
])iis  may  contain  bile,  carious  bone,  or  caseous  material,  but  usually  it 
is  very  foul,  as  is  the  fact  when  the  appendix  is  primarily  involved. 
In  many  of  the  cases  pis  alone  or  gas  with  but  little  pus  may  be 
present.  Various  reasons  are  ascribed  for  this  but  it  is  probably 
due  to  bacterial  proliferation,  the  colon  bacillus  being  usually 
found. 

Symptoms. — The  symptoms  of  subphrenic  abscess  vary  from 
those  of  a  very  mild  infection  with  practically  no  rise  in  tempera- 
ture and  pulse  and  no  leucocytosis,  to  the  most  severe  type  of  peri- 
tonitis. Usually  the  patient  will  complain  of  pain  in  the  right  side 
in  attempting  to  take  a  full  breath,  ('hilly  sensations  are  followed 
by  chills,  fever,  sweating  and  the  pain  increases  in  severity  so  that 
the  patient  is  able  to  take  only  very  shallow  breaths.  A  cough  de- 
velops with  the  irritation  of  the  diaphragm.  A  leucocytosis  now 
occurs  and  the  patient  settles  down  to  a  siege  of  sepsis.  On  ex- 
amination an  involvement  of  the  base  of  the  lung  will  be  found,  but 
there  may  or  may  not  be  dullness.  Later  on,  however,  there  will 
appear  an  area  of  dullness  in  this  region  with  lessened  breath 
sounds  and  fremitus.  It  must  be  remembered  that  the  line  of  dull- 
ness will  curve  upwards  in  this  condition  in  contradistinction  to 
fluid  in  the  pleural  cavity.  At  times  these  sm-ns  may  be  noted  an- 
teriorly and  in  addition  pleural  friction  sounds  may  be  present. 
As  the  condition  progresses  there  may  be  flattening  of  the  inter- 
costal spaces  or  bulging  of  the  chest  wall  itself.  The  swelling  may 
appear  in  the  epigastrium  or  below  the  border  of  the  ribs  and  be 
associated  with  a  local  edema,  depending  upon  the  location  of  the 
pus.  The  outline  fluid  will  not  change  with  different  postures  of  the 
patient,  bul  will  remain  in  one  position.  Neither  will  the  heart  be 
dislocated  as  is  seen  at  times  in  pleuritic  effusions,  unless  possibly 
it  is  pushed  upwards.  In  .1  of  the  21  eases  reported  by  Koss  com- 
ing to  autopsy  there  were  purulent   pleurisy. 


SUBDIAPHRAGMATIC    EMPYEMA  297 

Abdominal  symptoms  do  not  always  occur  due  to  the  deep  loca- 
tion of  the  abscess;  when  present,  however,  pain  and  tenderness 
will  be  noted  and  the  mass  may  be  felt  in  the  epigastrium.  The 
pain  as  stated  above  is  usually  a  pleural  pain  and  elicited  abdom- 
inally by  deep  palpation.  The  cases  in  which  symptoms  were  de- 
layed for  months,  reported  by  Ashhurst19  and  Meisel20  showed  a 
more  or  less  sudden  onset  and  the  complication  was  apparent  as  a 
grave  abdominal  condition. 

When  this  complication  presents  itself,  as  early  a  diagnosis  as 
possible  should  be  made.  Since  the  abscess  so  often  contains  gas 
which  may  be  mistaken  for  a  pneumothorax  or  even  for  a  hollow 
viscus,  it  may  not  be  possible  to  make  a  diagnosis  without  first  free- 
ing the  stomach  of  gas  by  means  of  a  stomach  tube  and  then  ap- 
plying the  aspirating  needle  to  the  affected  side.  This  can  give 
important  evidence  as  to  the  location  of  the  pus.  If  the  abscess 
communicates  with  the  pleural  cavity  the  needle  will  move  up  and 
down  with  the  respiratory  movements ;  or  by  immersing  the  end  of 
the  needle  in  sterile  water  one  may  be  able  to  see  the  expulsion  of 
gas  with  those  movements  of  the  diaphragm.  These  signs  will  fail 
at  times  due  to  the  localized  paralysis  of  the  diaphragm  caused  by 
the  inflammation  or  pressure  of  the  fluid  upward.  Adhesions  may 
also  produce  the  same  effect,  Only  the  most  careful  study  of  the 
individual  case  will  effect  even  an  approach  to  a  diagnosis.  The 
leucocytes  in  Judd's  case  ranged  from  8,800  to  22,000.  The  dura- 
tion of  the  disease  varied  from  three  days  to  ten  months.  In  four 
of  his  cases  the  x-ray  was  used  to  good  advantage  in  distinguish- 
ing between  this  condition  and  others  above  the  diaphragm. 

Treatment. — The  treatment  consists  firstly  in  anticipation  of  this 
complication  during  operations,  appendicitis  with  pus  behind  and 
to  outer  side  of  the  ascending  colon.  The  prone  position21  with  suffi- 
cient flank  drains  in  such  cases  will  aid  materially  in  preventing  a 
subphrenic  abscess  from  developing.  This  position  is  better  than 
the  Fowler  immediately  following  the  operation,  since  the  heart  is 
not  put  on  an  additional  strain,  while  drainage  is  definitely  assisted 
by  the  influence  of  gravity.  After  twenty-four  hours  the  patient 
lies  on  the  right  side  as  much  as  possible.  When  the  drainage 
ceases,  he  can  assume  any  position,  though  he  is  enjoined  from 
lying  on  the  back  very  long  at  a  time  during  any  phase  of  the  con- 
valescence. 

In  spite  of  these  preventive  measures  the  condition  may  occur. 
It  should  always  be  suspected  in  any  such  case  which  shows  more 
toxic  symptoms  than  can  be  accounted  for.     An  early  diagnosis  made 


298  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

by  the  aspirating  needle  or  any  other  means  at  our  command  will 
materially  lessen  the  severity  of  this  complication. 

The  prognosis  is  thereby  improved  though  it  is  serious  enough 
under  any  circumstances.  Depending  upon  the  virulence  of  the 
infection,  the  patient  may  die  within  a  few  hours  or  he  may  live 
several  months.  Recovery  may  result  by  rupture  of  the  abscess 
into  a  bronchus  directly  or  indirectly  by  way  of  the  pleura.  The 
abscess  rarely  empties  itself  into  any  of  the  abdominal  viscera  or  ex- 
ternally.    Death  is  most  apt  to  occur  from  sepsis. 

The  mortality  depends  upon  the  origin  of  the  abscess  and  upon 
the  date  of  operation  employed  for  its  relief.  If  such  measures  are 
attempted  early,  the  mortality  is  around  16  per  cent ;  but  if  de- 
layed as  late  as  three  weeks,  it  goes  above  50  per  cent.  If,  how- 
ever, no  operation  at  all  is  done  the  mortality  varies  from  55  per 
cent  to  7'2  per  cent  according  to  Sonnenberg  and  Sachs,  respec- 
tively. Of  Judd's  cases,  11  died  due  to  the  extension  of  the  process 
to  the  liver  with  the  formation  of  multiple  abscesses  which  could 
not  be  adequately  drained  by  any  operative  procedure. 

Under  local  anesthesia  vide  and  free  incisions  should  be  made 
in  an  effort  to  get  adequate  drainage^  According  to  Ross  the  va- 
rious operations  for  this  condition  are  classified  in  three  groups. 
The  abdominal  operation  may  be  carried  out  below  the  ribs,  in  the 
epigastric  region  or  in  the  loin,  depending  upon  the  location  of  the 
abscess.  The  subplcural  route  consists  in  resecting  the  tenth  rib  in 
the  midaxillary  line  and  traversing  the  diaphragm  below  the  pleu- 
ral reflection. 

Probably  the  transpleural  route  is  the  one  preferred  by  most  op- 
erators. The  technic,  as  employed  by  Elsberg,  consists  in  resecting  the 
the  ninth  and  tenth  ribs  s ewhere  between  the  scapular  and  axil- 
lary lines.  The  surfaces  of  the  pleura  should  be  carefully  sewed 
together  to  prevent  pus  from  disseminating  throughout  the  thoracic 
cavity.  Large  rubber  tubes  should  be  employed  and  the  patient 
treated  Hie  same  as  an  empyema  case.  No  matter  where  the  drain 
is  inserted,  the  patient  must  be  so  placed  that  the  opening  coin- 
cides with  the  dependent  portion  of  the  body.  The  most  effective 
and  complete  drainage  is  secured  in  this  way  alone. 

Bibliography 

iJopson:      Ar.-li.  Pediat.,  L904,  xxi.  No.  2. 

zWright:     Am.  Jour.  Med.  Sc,  1829,  iv,  353. 

•'■Marlmv  and  Wilks:     London  Med.  Gaz.,  L845,  i.  X".  5,  p.   L3. 

*Duchek:      Prager  Vierterjahreschrift,   1853. 

sBamberger:     Verhandl.  der  phys.  tried.  Gesselschaft  zu  Wiirzburg,  1858,  iii,  L23, 


SUBDIAPHRAGMATIC   EMPYEMA  299 

eBernheim:      Virchow-Hirsch  Jahresbericht,   1874. 

TPatsch:     Loc.  cit.,  1882,  p.  300. 

sTaylor:     Guy's  Hosp.  Beports,  xix. 

sFitz:      Tr.  Assn.  Am.  Phys.,  i,  1886. 
loLeydon:     Beii.  klin.  Wchnschr.,  Nov.   14,  1892. 
"Treves:     Operative  Surg.,  London,  1905. 
i2Boss:     Jour.  Am.  Med.  Assn.,  1911,  lvii,  526. 
"Barnard:     Brit.  Med.  Jour.,  1908,  i,  371. 
"Lance:     Gaz.  d.  hop.,  Paris,  1909,  lxxxvi,  63,  99. 
isCosentino :     Polielinieo,  Borne,  1907,  xix,  sez.  ehir.  pp.  251,  386. 
isJudd:     Journal-Lancet,   1915,  xxxv,  621. 
i^Kelly  and  Hurdon:     Boston  City  Hosp.  Bept.,   1905. 
isPiquand:     Bev.  de  cliir.,  1909,  xxxix,  150. 
isAshhurst:     Tr.  Phila.  Acad.  Surg.,  1910,  xiii,  154. 
soMeisel:     Miinchen  med.  Wchnschr.,  1909,  lvi,  1411. 
siGhent :     Jour. -Lancet,  1916,  xxxvi,  194. 


CHAPTER  XXXVII 

THROMBOPHLEBITIS 

By  0.  F.  McKittrick,  St.  Louis.  Mo. 

Postoperative  thrombophlebitis  is  of  such  common  occurrence 
that  it  enters  into  the  experience  of  every  surgeon,  and  yet,  not- 
withstanding the  advance  in  postoperative  treatment  in  recent 
years,  it  is  still  so  common  and  the  consequences  may  he  so  dire 
that  it  remains  a  bete  noire  of  the  surgical  profession. 

This  condition  occurs  most  frequently  after  abdominal  opera- 
tions, bu1  it  may  1'ollow  operations  on  distant  parts  of  the  body.1  It  is 
especially  common  after  operations  on  the  uterus  and  adnexa  and 
in  operations  about  the  rectum.  This  condition  rarely  occurs  be- 
fore the  age  of  puberty,  and  with  the  greatest  frequency  after 
thirty.  Thrombophlebitis  develops  in  clean,  as  well  as  septic  cases;1 
the  thrombosis  forming  at  times  far  from  the  operative  field.  The 
left  (due  to  the  righl  common  iliac  artery  crossing  in  front  of  the 
left  common  iliac  vein  I  femoral  vein  and  the  veins  of  the  calf  and 
thigh  arc  most  commonly  affected,  though  the  external  iliac,  the 
common  iliac,  the  mesenteric,  and  the  portal  veins  have  been  in- 
volved in  this  malady.  From  a  study  of  a  large  series  of  statistics, 
thrombophlebitis  occurs  in  from  .81  per  cent  to  3.6  per  cent  of  all 
laparotomies.  Burnham2  reported  the  former,  and  Friedman,3  the 
latter  figure.  It  was  also  noted  that  the  earliest  onset  of  tin'  dis- 
ease came  after  four  days,  and  the  latesl  onset  after  twenty-eight 
days.  Generally  debilitated  or  anemic  subjects,  those  who  have 
suffered  from  profuse  ami  prolonged  Menorrhagia  due  to  the  pres- 
ence of  a  submucous  fibroid,  or  those  who  have  been  suhjected  to 
a  prolonged  operation,  formed  the  bulk  of  the  patients  affected  as 
above.  I  saw  fatal  disease  of  the  long  saphenous  vein  follow  an 
operation  near  a  varicose  ulcer. 

More  than  sixty  years  ago  Virchow  called  attention  to  throm- 
bosis; ami  although  he  did  Qot  distinguish  it  from  coagulation,4  his 
studies  were  early  confirmed  by  numerous  experimental  and  post- 
mortem observations  by  others,  chief  among  whom  were,  Cohnheim 
and  Colin:  when  with  this  work  Ave  place  Welch's  classical  review 
of  "Thrombosis  ami  Embolism"  published  in  ]^!i!),  we  have  listed 
most  of  the  significant  literature  on  this  subject.5 

Today  the  meaning  of  the  term  has  changed  and  by  thrombosis 

300 


THROMBOPHLEBITIS  301 

is  meant  the  formation  and  organization,  during  life,  of  a  blood 
clot  in  a  vessel.  The  mechanism  is  so  simple,  as  it  is  taught  at  the 
present  time  that  we  wonder  why  it  was  necessary  for  Virchow  to 
establish  the  self-evident  fact  that  injury  to  a  vessel  or  changes  in 
the  blood  sufficient  to  cause  clotting  at  some  particular  point  might 
be  followed  by  dislodgment  of  a  piece  of  the  solid  clot,  and  this 
broken  off  mass  be  carried  on  by  the  blood  stream,  until  it  reached 
a  vessel  too  small  for  it  to  pass  through,  then  stop.  It  is  also  plain 
that  the  blocking  of  a  vessel  by  this  solid  mass  would  stop  the  cir- 
culation through  this  vessel,  and  give  rise  to  disturbances  of  great 
importance,  or  of  little  importance,  depending  on  whether  or  not 
this  vessel  supplied  an  organ,  the  function  of  which  was  necessary 
to  maintain  life.  Increased  coagulability  is  probably  not  alone  re- 
sponsible for  thrombosis,  though  Wright  and  Knapp,6  in  1902 
stated  that  thrombosis,  particularly  after  typhoid,  was  due  to  in- 
creased coagulability  of  the  blood,  as  the  consecoience  of  the  high 
calcium  content  which  they  attributed  to  the  milk  diet. 

The  modern  theory,  which  is  generally  accepted,  is  in  accord 
with  the  teaching  of  Eberth  and  Schimmelbusch,  who  belieA'e  that 
the  blood  platelets  play  a  prominent  part  in  thrombosis,  but  little 
or  no  part  in  coagulation.  On  the  other  hand,  fibrin  and  its  pro- 
geners  although  normally  active  in  coagulation,  play  only  a  minor 
part  in  the  formation  of  a  thrombus.  Blood  platelets,  numbering 
from  180,000  to  780,000  per  c.mm.,  according  to  Bizzero,  although 
normal  constituents  of  the  blood,  are  the  originators  of  the  typical 
thrombus.  They  may  collect  about  a  foreign  body  or  following  a 
slowing  of  the  blood  stream,  collect  upon  the  damaged  wall  of  a 
vessel.  This  agglutinative  process  takes  place  only  in  the  circulat- 
ing blood,  for  there  is  no  thrombus  formation  when  a  vein  is  doubly 
ligatured  and  excised,  according  to  Baumgarten.  Following  the 
throwing  down  of  the  blood  platelets  there  is  a  rapid  accumulation 
of  polymorphonuclear  leucocytes,  and  to  this  nucleus  is  added  fi- 
brin mixed  with  red  cells. 

Aschoff  states  that  a  change  in  the  character  of  the  blood  is  nec- 
essary for  thrombus  formation.  He  holds  that  the  location  of  the 
thrombus  is  determined  by  slowing  of  the  blood  stream,  or  by  the 
widening  of  the  vein,  with  resulting  eddy  formation ;  from  repeated 
examinations  of  the  blood  Burnham  concludes  that  there  is  no  de- 
crease in  the  coagulation  time  in  postoperative  thrombophlebitis, 
and  while  it  has  been  suggested  that  an  increased  viscosity  will 
cause  a  slowing  of  the  blood  stream,  it  has  not  been  sufficiently 
tested  in  postoperative  eases.     Bachman  has  shown  that  it  is  in- 


302  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

creased  in  infectious  diseases,  especially  typhoid,  while  it  has  been 
definitely  proved  that  in  those  diseases  in  which  the  blood  platelets 
are  increased,  thrombosis  is  common. 

Chemical  changes  may  influence  the  formation  of  thrombi.  Sahli 
and  Egnet  showed  that  they  did  not  form  after  the  injection  of 
leech  extract,  since  the  blood  was  rendered  noncoagulable,  while 
Sehimmelbusch,  on  the  other  hand,  was  able  to  cause  a  formation  of 
experimental  thrombi  after  destroying  the  coagulability  of  the 
blood  by  the  injection  of  peptone. 

FaueheauxV  belief  that  the  increased  sodium  content  of  the  blood 
due  to  a  temporary  insufficiency  of  the  kidney,  may  be  a  predis- 
posing cause,  is  not  convincing. 

Albanus8  gives  as  prevailing  causes  for  thrombosis  after  laparot- 
omies, "sepsis,  heart  derangements,  pressure  of  tumors  on  veins. 
cooling  and  handling  of  blood  vessels  while  the  abdomen  is  open;  the 
effect  of  narcosis  on  the  heart,  the  recumbent  position  and  the  pres- 
sure of  a  bandage." 

Infection  apparently  plays  a  part,  though  no  definite  proof  can 
be  cited  for  or  against  this.  Heidemann  lias  called  attention  to  the 
period  of  incubation  and  holds  the  entire  process  to  be  infections 
in  character.  Klein0  argues  against  this  and  points  to  the  afebrile 
cases  as  an  argument  against  infection:  but  as  pointed  out  by 
Fromme,  many  slight  rises  of  temperature  may  be  overlooked,  and 
moreover,  infection  may  occur  without  any  febrile  reaction  what- 
ever, Lubarsch  could  demonstrate  organisms  in  only  20  out  of  215 
cases. 

After  an  examination  of  a  large  number  of  records  it  is  impossi- 
ble to  exclude  the  process  as  a  result  of  the  milder  self -limiting  types 
of  nonpyogenic  inflammations.  That  it  may  be  initiated  by  mechan- 
ical or  chemical  factors  or  both  is  doubtless  true,  but  the  course  and 
symptoms  of  the  disease  are  too  typical  of  infections  to  allow  of 
any  other  conclusion  in  most  instances. 

Then  it  seems  to  me,  as  it  was  also  suggested  by  AVilson10  that 
the  most  important  factors  concerned  in  extensive  postoperative 
thrombosis  are  the  following:* 

(a)  Injury  of  the  vessel  Avails.  Injury  to  the  intima  by  cutting. 
ligating  or  clamping  causes  a  rapid  deposite  of  a  fibrinous  throm- 
bus, formed  as  depicted  in  the  theory  of  Eberth  and  Schimmel- 
busch.  The  deposit  confines  itself  within  an  area  close  to  the  in- 
jury, the  endothelium  quickly  extends,  and  after  a  few  days  covers 
it  entirely,   thereby  preventing  portions   becoming  detached    and 


*Much  of  the  following  is  taken  from  Wilson's  article.10 


THROMBOPHLEBITIS  303 

forming  emboli.  However,  there  are  other  instances  in  which  this 
limitation  fails  to  occur  and  the  small  attached  thrombi  develop 
into  large  loose  ones  through  the  agencies  of  other  factors. 

(b)  Slowing  of  the  blood  stream.  Following  operations  the  ra- 
pidity and  volume  of  the  current  in  the  veins  are  materially  les- 
sened for  a  considerable  distance  nearest  the  first  incoming  venous 
radicals.  The  patient  being  kept  quiet  and  in  the  recumbent  pos- 
ture causes  a  slowing  of  the  heart's  action  and  diminishes  its  force, 
thereby  causing  a  general  slowing  of  the  blood  current  throughout 
the  entire  vascular  system.  This,  according  to  Opie,  produces  a 
disarrangement  in  the  blood  cells,  the  white  cells  and  platelets 
reaching  the  periphery  of  the  stream  tend  to  attach  themselves  to 
the  vascular  walls.  In  the  presence  of  obstacles  or  marked  expan- 
sion of  the  vessel  a  whirling  motion,  as  shown  by  von  Reckling- 
hausen, may  be  set  up  which  further  tends  to  the  retardation  of  the 
blood  stream  and  to  the  deposition  of  its  elements  as  thrombi. 

(c)  Destruction  of  corpuscles  from  toxic  substances.  From  the 
high  percentage  of  postoperative  thrombosis  and  embolism  follow- 
ing gall  bladder  operations  and  the  behavior  of  cases  suffering 
from  severe  secondary  anemias  and  hepatic  diseases,  to  say  nothing 
of  thrombosis  in  carcinoma  cases,  it  is  fair  to  assume  that  some 
toxic  substance  or  substances  not  definitely  known  are  present  in 
the  blood. 

(d)  Bacteriemia.  It  is  now  fairly  well  established  that  bacteria 
and  their  toxins  are  the  chief  causes  of  extensive  postoperative 
thrombosis,  many  thrombi  which  we  formerly  regarded  as  "maran- 
tic," in  the  light  of  the  last  decade  of  pathologic  advancement,  we 
now  know  are  of  infective  origin.  It  is  readily  conceivable  that  bac- 
teria in  the  blood  stream  may  have  their  virulence  sufficiently  reduced 
to  prevent  them  setting  up  a  local  phlebitis  until  aided  by  postopera- 
tive traumatism  of  the  intima,  by  postoperative  slowing  of  the  blood 
current,  or  perhaps  even  by  the  effect  on  the  leucocytes  of  a  pro- 
longed general  anesthetic. 

Symptoms. — The  symptoms  of  thrombophlebitis  depend  upon  the 
location  of  the  thrombus.  In  rare  instances  in  which  the  portal  vein 
is  involved,  the  course  is  very  rapid,  marked  by  extreme  prostration, 
chills  and  an  irregular  high  temperature.  The  condition  simulates 
very  closely  that  of  acute  peritonitis.  There  is  usually  tenderness 
along  the  outer  border  of  the  right  rectus  muscle,  enlargement  of  the 
liver  and  spleen  and  at  times  jaundice  may  be  present.  Such  a  condi- 
tion following  appendectomy  is  highly  suspicious  of  pylephlebitis.  Af- 
fection of  the  mesenteric  artery  is  more  common,  and  from  the  statis- 


304 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


tics,  the  sudden  onset  of  acute  pain,  more  or  less  diffuse  over  the 
entire  abdomen  with  a  decided  rigidity  with  vomiting,  usually  blood 
stained,  and  in  the  very  early  stage,  diarrhea  with  bloody  stools,  are 
the  most  constant  symptoms.11  Gerherdt12  notes  in  addition  to 
the  above,  ileus,  fluid  in  the  abdomen,  a  rapid  fall  in  tem- 
perature and  a  large  palpable  mass  between  the  layers  of  the 
mesentery.  Fortunately  where  the  condition  is  most  common  the 
symptom-complex  is  pathognomonic.    Blood  clots  in  the  veins  of  the 


Fig.    43.  — Wrapping   the    leg   in   common   cotton   batting. 

pelvis  or  lower  extremities,  offer  no  symptoms  to  attract  attention 
so  long  as  they  are  not  infected.  When  infection  occurs,  however, 
a  mild  initiative  chill  is  noted,  followed  by  a  temperature  probably 
103°  C.  with  a  corresponding  pulse.  At  the  point  of  the  lesion  there 
will  be  tenderness  and  swelling  and  the  whole  limb  on  the  affected 
side  may  become  swollen  and  painful.  If  the  saphenous  vein  is  in- 
volved, the  veins  distal  to  the  affected  portion  stand  out  like  cords, 
their  course  being  marked  by  the  \'ci\  lines  upon  the  skin  over  them, 
due  to  the  accompanying  Lymphangitis. 


THROMBOPHLEBITIS 


305 


Treatment. — In  view  of  the  facts  elucidated  above,  the  treatment 
of  thrombophlebitis  concerns  itself  first  with  the  prevention  of  this 
condition.    The  following  suggest  themselves:* 

(a)  The  reduction  of  vascular  traumatism  to  a  minimum  at  op- 
eration by  the  conservative  occlusion  of  vessels  and  the  provision  of 
free  drainage  to  prevent  later  external  pressure  on  the  vessels. 

(b)  The  encouragement  of  very  early  free  movement  on  the  part 
of  the  patient,  as  soon  as  the  nature  of  the  operation  will  permit ;  if 
it  can  be  clone  early  enough  to  prevent  the  formation  of  extensive 
thrombi,  it  would  seem  most  desirable.     If,  on  the  other  hand  condi- 


Fig.  44. — The  leg  is  kept  elevated  and  splinted  on  a  pillow. 


tions  are  such  as  to  lead  to  the  suspicion  that  extensive  thrombi  have 
already  formed  before  the  early  movements  of  the  patient  were  pos- 
sible, it  would  then  seem  more  desirable  to  keep  the  patient  as  quiet 
as  practical  in  a  recumbent  position  to  prevent  a  dislocation  of  the 
already  formed  thrombi.  Just  when  to  allow  the  patient  out  of  bed 
under  such  conditions  depends  upon  the  experience  and  skill  of  the 
surgeon.     No  one  can  estimate  the  time  required  for  the  formation 

*Much  of  the  following  is  taken   from  Wilson's  article.10 


306 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


of  extensive  postoperative  thrombi  in  any  one  case.  We  do  know, 
however,  that  loose  thrombi  are  readily  dislocated  by  a  very  slight 
exertion  on  the  part  of  the  patient. 

(c)  The  preoperative  administration  of  drugs  to  increase  the  co- 
agulability of  the  blood,  as,  for  example,  calcium  salts;  while  these 
tend  to  produce  an  increased  coagulation  time  there  is  no  evidence  to 
show  that  they  are  of  value  in  thrombosis. 

(d)  Measures  looking  toward  the  reduction  of  bacteriemia  are 
certainly  indicated  as  a  preoperative  precaution.  For  the  prevention 
of  thrombosis  the  cautery  should  be  used  wherever  possible  at  the 
operation  to  destroy  the  local  foci.  If  the  invading  organism  can 
be  isolated,  autogenous  vaccines  may  be  made  and  preliminary  vac- 
cination be  carried  out. 


Fig.   45. — The  extremity  is  protected   from   the  lied   covers,  and  a  hot-water  bottle  applied   to 

the   sole   of   the   foot. 


Where  the  condition  lias  already  occurred,  absolute  rest  in  bed 
must  be  carried  out  for  five  or  six  weeks.  Under  no  circumstances 
should  the  patient  lie  allowed  but  the  slightest  movements.  Particu- 
larly after  the  third  week  when  the  clot  has  become  brittle  and  Likely 
to  disintegrate  should  the  patient  be  enjoined  from  getting  out  of 
hed  or  straining  at  stool.  The  bowels  can  be  kept  normal  with  min- 
eral oil  given  during  the  meals  and  if  necessary  enemas  to  enhance 
the  action  of  this  mild  drug. 


THROMBOPHLEBITIS  307 

The  leg  should  be  wrapped  (Fig.  43)  in  cotton  and  elevated  (Fig. 
44),  hot-water  bottle  applied  to  the  foot  (Fig.  45),  and  after  the 
acute  symptoms  have  subsided,  over  the  site  of  the  lesion  also.  Until 
then  ice  should  be  placed  here.  Pain  will  thereby  be  relieved ;  but  if 
this  is  not  sufficient,,  opium  may  be  resorted  to.  If  necessary  the  vein 
may  be  opened  and  drained.  The  following  history  may  be  of  in- 
terest. 

February  28,  1916,  Mrs.  S.,  age  twenty-four,  was  operated  for  tuberculous 
peritonitis  and  a  double  salpingectomy  was  done.  The  operation  was  quickly 
performed,  produced  very  little  shock,  and  the  patient  was  returned  to  bed  in 
good  condition.  The  temperature  was  101°  at  operation  with  a  corresponding 
pulse;  and  continued  so  high  for  four  days  following.  Urination  was  normal, 
bowels  were  moved  with  glycerin  enemas  on  the  second  day  and  there  were  scarcely 
any  gas  pains.  In  the  meantime  frequent  feedings  of  thick  liquids  were  carried 
out,  the  food  was  taken  with  a  relish  and  the  patient  felt  so  well  that  on  the 
night  of  the  third  day  she  asked  to  sit  up  on  the  morrow.  The  following  morn- 
ing the  temperature  had  dropped  to  98.6°  with  a  pulse  of  90,  and  her  request  was 
about  to  be  considered  favorably  when  suddenly,  about  noon,  patient  noticed  a 
stinging  pain  on  the  inner  side  of  the  ankle,  which,  after  an  hour  or  so,  extended 
along  the  inner  side  of  the  leg  and  thigh.  Pressure  along  the  course  of  the  in- 
ternal saphenous  vein  was  unbearable.  The  afternoon  temperature  was  102.4°, 
but  there  was  little  change  in  the  pulse.  The  whole  limb  was  well  wrapped  in 
cotton  batting  and  elevated  on  a  high  stack  of  pillows.  A  wire  cage  placed  over 
this  protected  the  dressing  from  being  disturbed  by  the  bed  clothes.  An  ice  cap 
was  placed  over  the  lesion  in  the  thigh  and  a  hot-water  bag  at  the  foot.  The 
pain  was  relieved  at  once  by  this  treatment  which  never  varied  (except  the  ice 
cap  was  replaced  at  the  end  of  the  third  day  by  a  hot-water  bag),  as  long  as 
there  were  any  indications  of  the  lesion  remaining.  For  nine  days  the  morning 
temperature  remained  101°  while  the  afternoon  temperature  continued  to  reach 
the  102.4°  mark.  All  the  while  patient  was  at  perfect  ease;  two  days  following 
the  accident  the  diet  was  increased  to  a  general  one,  and  a  day  or  so  later  it  was 
forced,  carrots  and  spinach  being  given  in  abundance.  At  all  times  there 
was  a  good  supply  of  water,  sodium  bicarbonate  being  given  at  times  to  prevent 
a  possible  acidosis.  Bowels  were  kept  open  with  glycerin  enemas,  2  ounces  every 
second  day  unless  there  was  a  movement  without  them.  On  the  ninth  day  of  the 
disease  and  the  fifteenth  following  the  operation,  the  temperature  fell  to  99°. 
From  this  time  on  there  was  very  little  fever.  The 'limb  was  gradually  lowered 
and  after  four  more  days'  stay  in  the  hospital  with  the  limb  horizontal,  the 
patient  was  able  to  get  out  of  bed,  and  as  soon  as  the  equilibrium  became  estab- 
lished (one  day  up  and  about  the  hospital),  she  went  home.  Xo  further  compli- 
cation or  untoward  symptoms  developed  following  the  use  of  the  limb.  I  at- 
tribute the  quick  recovery  to  immediate  attention  to  the  phlebitis,  thereby  pre- 
venting nature  from  forming  but  a  small  thrombus. 

Bibliography 

iBull:     Beitr.  z.  klin.  chir.,  1912,  lxxxii,  345. 

^Burnham:     Ann.  Surg.,  1913,  lvii,  151. 

3Friedman :     Quoted  by  Burnham.2 

^Virchow:      Gesanrnielte  abhandlungen.     Frankfurt  a.  M.,  1856. 


308  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

sWelch:     Allbutt's  System  of  Medicine,   1899,   vii,  pp.   155-159. 

'■Wright  and  Knapp:      Med.  Cliir.  Trans.,  London,   1903,  No.   1. 

^Faucheaux:     Paris  These,  1905. 

sAlbanus:      Beitr.   z.  klin.   Chir.,  xl. 

olvlein:     Arch.  f.  Gvniik.,  xeiv,  No.   1,  p.   1911. 
loWilson:     Ann.  Burg.,  1912,  hi,  S09. 
uLaplace:     Pennsylvania  Med.  Jonr.,  1913,  xvi,  <i'»!». 
isGerherdt:     Quoted  by  Laplace.1* 
The  following  references  were  also  consulted : 
Buerger:     Jour.  Am.  Med.  Assn.,  1909,  lii,  p.  1319. 
Clutton-Allbutt  and   Rolleston's  System   of  Medicine,   vi,   681. 
Cordier:     Jour.  Am.  Med.  Assn.,  1905,  xlv,  1792. 
Friedemami :     Beitr.  z.  klin.  Chir.,  1910,  lxix,  No.  2. 
Jouglard:      Paris   These,   1902. 
Kronig:     Operative  Gynakologie,  1907. 

Mahler:     Arbeiten  aus  der  kgl.  Frauendlinic,  Dresden,  1905. 
Noland,  L.,  and  Watson,  F.  G.,  Ann.  Surg.,  1913,  lviii,  459. 
Schenck:      Tr.  Am.  Gynec.  Assn.,  May,  1913. 
Voelcker:     Deutsch.  Gesellsch.  f.  chir.,  1914. 
Wallace,  R. :     Am.  Jour.  Surg.,  1914.  xxviii,  103. 
Welch-Allbutt  and  Rolleston's  System  of  Medicine,  vi,  691. 


CHAPTER  XXXVIII 

PULMONARY  EMBOLISM 
By  "Willard  Bartlett,  St.  Louis,  Mo. 

When  one  considers  that  it  was  not  until  the  first  quarter  of  the 
seventeenth  century  that  the  circulation  of  the  blood  was  discovered, 
it  is  hardly  surprising  that  two  hundred  years  more  should  have 
elapsed  before  it  occurred  to  any  one  that  this  flowing  stream  could 
act  as  a  means  of  transportation  for  solid  particles  set  free  in  its 
current,  and  that  said  particles  could  find  lodgment  at  some  point 
other  than  that  of  entry. 

Rudolph  Virchow  was  the  first  to  teach  that  injury  to  a  vessel 
wall  or  changes  in  the  blood  sufficient  to  cause  clotting  at  some  one 
site  might  be  followed  by  dislodgment  of  a  portion  of  the  clot,  which 
could  be  carried  along  in  the  blood  stream  until  it  reached  a  vessel 
too  narrow  for  it  to  pass,  and  there  become  tightly  wedged.  Nat- 
urally this  is  bound  to  stop  the  circulation  of  blood  through  a  ves- 
sel thus  affected,  and  give  rise  to  circulatory  disturbances  in  the 
vicinity,  of  great  or  little  importance,  depending  upon  whether  the 
vessel  affected  is  a  terminal  branch. 

In  this  chapter  I  shall  discuss  venous  thrombosis  after  surgical 
operations,  followed  by  the  liberation  of  emboli  sufficient  in  size  or 
number  to  block  completely  the  more  important  branches  or  a  main 
stem  of  the  pulmonary  artery,  so  as  in  many  instances  to  cause  sud- 
den death. 

Pulmonary  embolism  frequently  follows,  and,  in  fact,  is  a  natural 
sequence  to  thrombophlebitis.  The  factors  concerned  in  the  forma- 
tion of  a  thrombus  as  mentioned  elsewhere  in  this  work  are  of  vital 
importance  here,  since  the  condition  is  due  to  the  whole  or  a  portion 
of  the  blood  clot  becoming  dislodged,  and  floating  free  in  the  blood 
stream  until  finally  it  stops  when  a  vessel  is  reached  too  small  for  it 
to  pass  through.  Thrombosis  most  commonly  occurs  in  the  pelvic 
veins  and  in  those  of  the  lower  extremities  following  laparotomy. 
This  fact  is  not  surprising  when  it  is  remembered  that  pelvic  and 
abdominal  operations  are  more  frequently  performed  than  are  op- 
erations on  other  parts  of  the  body,  and  that  operations  anywhere, 
if  veins  are  subjected  to  trauma  or  infection,  are  likely  to  be  fol- 
lowed by  this  condition  and  by  subsequent  embolism. 

309 


310 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


Cases  of  blocking  of  the  pulmonary  artery  by  a  mass  of  clot  broken 
off  from  a  venous  thrombus  are  by  no  means  uncommon.  They  occur 
most  frequently  between  the  second  and  fourth  week  after  operation. 
The  patient  may  die  at  once,  there  may  be  a  more  or  less  prolonged 
respiratory  struggle  ending  in  death,  and  in  at  least  one  instance  the 
author  has  seen  complete  recovery.  The  outcome  depends  on  whether 
the  detached  mass  goes  through  the  right  heart  intact  in  sufficient 
size  to  completely  block  (Fig.  46)  the  pulmonary  artery,  whether  it 
partially  blocks  it,  or  blocks  one  of  its  main  divisions  and  is  then  in- 
creased in  size  by  other  following  masses  or  by  the  subsequent  coagu- 
lation of  blood  behind  the  obstructing  mass.     Immediate  death  fol- 


Fig.   46. — Complete   blocking   of    pulmonary    artery    by   embolus.      (After   Aschoff.) 

lows  the  complete  plugging  of  the  main  trunk  of  the  pulmonary  ar- 
tery. Sudden  death  may  occur  after  plugging  of  only  one  of  the  main 
branches,  provided  the  patient  lias  not  a  perfed  heart  muscle.  A 
perfect  heart  may.  on  the  other  hand,  withstand  the  effects  of  a  par- 
tial obstruction  of  this  kind. 

Anatomy. — Autopsy  findings  in  such  eases  are  exceedingly  scant. 
infarction  of  the  lung  being  seen  only  where  smaller  branches  of  the 
pulmonary  artery  have  been  affected.     Of  course  one  can  think  of 


PULMOXARY   EMBOLISM 


311 


cases  in  which  tiny  emboli  have  preceded  the  fatal  extensive  plug- 
ging and  thus  caused  limited  infarcts  before  sudden  death  took  place. 
This  is,  however,  the  exception  rather  than  the  rule,  and  is  usually 
due  to  the  fact  that  there  is  thrombosis  of  several  small  veins  at  the 
site  of  operation.  Any  of  these  thrombi  may  give  rise  to  emboli,  and 
a  small  embolus  may  be  carried  to  the  lung  at  any  time  from  one  of 
the  thrombi,  wholly  independent  of  the  large  embolus  which  caused 
death. 

Dr.  E.  L.  Thompson,  pathologist  to  the  St.  Louis  University,  who 
has  been  good  enough  to  cooperate  with  me  in  the  preparation  of  this 
chapter,  states  that  in  autopsies,  in  case  of  death  from  pulmonary  em- 
bolism, the  pulmonary  artery  should  be  examined  in  situ  before  the 


nJ]    ,,1-2-7 


Fig.    47. — Pulmonary   emboli   removed   at   autopsy.      (Mayo    Clinic   Collected    Papers,   vol.    ix.) 


heart  is  removed  or  cut  into,  as  the  site  of  an  embolus  is  usually  at 
the  point  (Fig.  47)  where  the  vessels  were  cut  in  removal  of  this  or- 
gan. If  this  be  not  clone,  the  embolus  which  may  have  not  as  yet  be- 
come attached  easily  slips  out  unobserved  and  may  be  entirely  over- 
looked by  the  pathologist. 

Pathogenesis. — The  origin  of  an  embolus,  while  it  may  come  from 
any  part  of  the  systematic  venous  system  or  from  the  right  heart,  is 
most  frequently  found  in  the  veins  of  the  lower  extremities,  in  the 
deep  epigastric  and  pelvic  veins,  or  in  those  of  the  mesentery. 

Albanus  gives  as  prevailing  causes  for  thrombosis  after  laparot- 
omy, sepsis,  heart  imperfections,  pressure  of  tumors  on  veins,  cool- 
ing and  handling  of  blood  vessels  while  the  abdomen  is  open,  the 
effect  of  necrosis  on  the  heart,  the  recumbent  position  and  the  pres- 
sure of  a  bandage.    He  overlooks  ivliat  I  believe  to  be  a  most  fruitful 


312  AFTER-TREATMEXT   OP    SURGICAL    PATIENTS 

cause  of  the  condition:  varicosities  on  veins  which  are  directly  af- 
fected  by  the  operation. 

On  the  operating  table  it  is  not  uncommon  to  see  greatly  changed 
veins,  carrying  the  blood  from  large  tumors,  and  in  one  instance,  at 
least,  of  our  series  No.  2.  Dr.  Thompson  and  I  were  able  to  demon- 
strate, both  at  operation  and  at  autopsy,  these  varicose  veins  and 
their  causal  relation  to  fatal  embolism. 

I  know  of  another  instance  in  which  varicose  veins  of  the  lower 
extremity  were  manipulated  by  well-intended  but  misdirected  mas- 
sage  about  a  knee  joint  which  had  remained  stiff  after  an  operation. 
The  result  was  a  sudden  fatal  pulmonary  embolism.  It  is  quite  ob- 
vious that  thrombi  had  formed  in  the  divided  varicose  veins,  had  been 
loosened  by  the  massage  and  swept  into  the  pulmonary  arteries. 

All  lung  symptoms,  according  to  Gussenbauer,  which  arise  after 
the  release  of  incarcerated  hernia  are  to  be  regarded  as  embolic  in 
nature.  Other  surgeons  go  equally  far  in  connecting  this  subject 
with  abdominal  surgery.  It  may  be  cited  as  an  instance  that  the 
Mayois,  when  resecting  the  stomach,  invariably  cauterize  the  cut  edges 
of  that  viscus  to  prevent  septic  pulmonary  embolism,  as  I  was  long 
ago  informed  in  a  personal  communication.  Since  doing  this,  they 
see  pulmonic  emboli  following  such  operations  much  less  frequently 
than  they  formerly  did. 

As  AlbanuSj  quoted  above,  states,  sepsis  is  naturally  to  be  thought 
of  as  a  factor  in  these  cases.  Hence  one  is  not  surprised  at  the  re- 
mark of  Sonnenburg  that  5  per  cent  of  all  appendix  operations  are 
attended  with  thrombosis  somewhere  in  the  vicinity.  No  doubt  he 
refers  to  the  acute  septic  variety. 

As  mentioned  above  the  reason  for  the  greater  number  of  cases 
given  in  the  literature  as  showing  thrombi  originating  from  the 
femoral,  epigastric  and  pelvic  veins,  so  far  as  the  surgeon  is  con- 
cerned, is  due  to  the  fact  that  pelvic  and  abdominal  operations 
are  much  more  frequently  performed  than  are  operations  in  other 
parts  of  the  body.  Such  procedures  elsewhere,  when  veins  are 
subjeel  to  trauma  or  infection,  are  apl  to  be  followed  by  throm- 
bosis and  subsequent  pulmonary  embolism,  as  they  are  in  the 
before-mentioned  situations.  This  is  well  illustrated  in  the  case 
of  a  man,  seventy  years  of  age,  whose  larynx  had  been  removed 
for  carcinoma  eight  days  before  sudden  death  ensued.  When  Dr. 
Thompson  made  the  autopsy  he  found  the  pulmonary  artery 
occluded  by  a  partially  organized  blood  clol  1.5  cm.  in  di- 
ameter. This  extended  into  both  main  divisions  of  the  artery.  The 
lungs  were  edematous  and  congested.    The  right  heart  was  distended 


PULMONARY   EMBOLISM  313 

and  full  of  blood.  The  neck  was  much  swollen.  The  operation 
wound  showed  some  superficial  necrosis,  with  healthy  appearing 
granulation  tissue  below.  On  the  right  side  the  internal  jugular  vein 
was  distended  to  a  diameter  of  3  cm.,  and  was  occluded  by  a  solid, 
grayisli,  granular  thrombus  for  a  distance  of  8  cm.  It  is,  of  course, 
reasonable  to  suppose  that  the  mass  occluding  the  pulmonary  artery 
had  broken  off  from  that  in  the  jugular. 

The  frequency  of  pulmonary  embolism,  including  the  cases  of  em- 
bolism of  the  smaller  branches  of  the  pulmonary  artery  that  give 
rise  to  little  or  no  permanent  after-effects,  is  much  higher  than  is  usu- 
ally supposed  after  surgical  operations. 

This  malady  is  as  frequent  in  one  sex  as  in  another,  but  does  not 
occur  before  the  fifteenth  year,  according  to  Petren.  This  author 
states  that  it  is  common  between  the  ages  of  thirty  and  forty-five,  but 
most  frequent  after  the  forty-fifth  year,  regardless  of  the  patient's 
general  condition. 

Virchow  found  in  ten  cases  of  thrombosis  of  the  veins  of  the  lower 
extremity  that  six  were  followed  by  pulmonary  embolism.  Albanus 
states  that  43  per  cent  of  the  cases  showing  thrombosis  after  laparot- 
omies were  followed  at  some  time  or  other  by  pulmonary  embolism. 
This  amounted  to  only  2  per  cent  of  the  patients  who  were  operated 
upon,  since  only  53  cases  of  thrombosis  were  found  following  1140 
laparotomies.  Of  these,  pulmonary  embolism  supervened  in  23  in- 
stances. Quenstedt  and  Leichtenstern,  on  the  other  hand,  both  found 
pulmonary  embolism  in  20  per  cent  of  their  thrombosis  cases.  Op- 
posed to  this,  again,  is  the  record  of  Lubarsch,  who  demonstrated 
pulmonary  embolism  347  times  in  584  instances  of  thrombosis ;  i.  e., 
in  59.1  per  cent  of  such  cases.  In  none  of  these  instances  is  it  stated 
how  frequently  the  embolus  was  of  sufficient  size  to  cause  death  by 
blocking  the  pulmonary  artery.  Such  cases  are  not  rare,  and  from 
those  which  have  been  reported  a  few  may  be  cited. 

Welch  has  collected  23  cases  of  venous  thrombosis,  in  which  there 
were  at  least  3  deaths  due  to  pulmonary  embolism  consequent  upon 
the  malady.  Mynter  mentions  a  patient  in  whom  sudden  death  was 
probably  due  to  pulmonary  embolism  following  thrombosis  of  the 
femoral  vein  in  appendicitis.  Robinson  describes  a  typical  death 
from  pulmonary  embolism  seventeen  days  after  a  hysterectomy. 
Koenig  reports  a  case  in  which  the  patient  died  from  pulmonary  em- 
bolism although  the  thrombosed  vein  (saphenous)  had  been  removed 
for  the  purpose  of  avoiding  just  such  an  untoward  outcome.  In 
this  instance  the  clot  probably  had  extended  into  the  femoral  vein 
and  was  therefore  not  to  be  extirpated. 


314  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

From  a  study  of  63,000  operations  performed  at  the  Mayo  Clinic. 
Wilson  found  47  instances  of  fatal  postoperative  embolism,  a  per- 
centage of  .07.  Over  three-fourths  of  these  fatalities  were  pulmon- 
ary, and  occurred  between  the  fifth  and  twelfth  days. 

From  the  cases  that  have  occurred  in  my  practice,  and  from  sev- 
eral that  came  to  autopsy  at  the  Boston  City  Hospital,  most  of  them 
during  the  service  of  Dr.  Thompson,  we  append  the  following  list: 

1.  Carcinoma  of  larynx.  Death  instantaneous  eight  days  after  op- 
eration. Occlusion  of  main  stem  of  pulmonary  artery  by  embolus. 
Thrombosis  of  internal  jugular  vein. 

2.  Myoma  of  uterus.  Death  sudden,  thirteen  days  after  operation. 
Occlusion  of  both  branches  and  trunk  of  pulmonary  artery  by  em- 
bolus.    Thrombosis  of  ovarian  veins. 

3.  Compound  fracture  of  leg.  Death  eight  days  after  injury. 
Main  trunk  and  right  pulmonary  artery  blocked  by  embolus.  Throm- 
bosis of  right  heart.     Culture  of  heart  blood  sterile. 

4.  Appendectomy.  Death  eight  days  after  operation.  Complete 
embolism  of  main  trunk  of  pulmonary  artery.  Pus  collection  at  the 
site  of  the  appendix. 

5.  Appendectomy.  Death  fifteen  days  after  the  operation.  Occlu- 
sion of  both  branches  of  pulmonary  artery  by  embolus.  Thrombus 
not  found. 

G.  Uterine  myoma  and  yall  stone  disease.  Six  days  after  opera- 
tion collapse  with  recovery.  Four  days  later  another  collapse  of 
similar  nature,  and  in  two  more  days,  that  is.  two  weeks  after  opera- 
tion, pulmonary  embolism  with  death  in  thirty  minute-. 

7.  Umbilical  herniotomy  and  Talma  operation  for  cirrhosis  of  liver. 
Death,  with  typical  symptoms  of  pulmonary  embolism,  eleven  days 
after  the  operation.  No  autopsy  could  be  obtained  in  this  or  in  the 
succeeding  eases,  which  occurred  in  private  practice,  hence  they  are 
submitted  not  as  proven  instances  of  pulmonary  embolism,  but  as 
-  ggestive  surgical  cases  in  which  a  better  explanation  of  death  can 
not  be  given. 

•s.  Hysterectomy  for  carcinoma  of  uterus.  A  woman,  four  weeks 
after  the  complete  Wertheim  operation,  was  up  and  preparing  to 
leave  the  hospital  when  she  suddenly  dropped  to  the  floor,  gasped 
for  breath,  and  was  dead  in  thirty  minute-. 

9.  Resection  of  stomach  for  carcinoma.  Three  days  after  the  op- 
eration the  patient,  an  elderly  man.  was  in  a  semi-sitting  posture, 
talking  to  his  nurse,  having  taken  liquid  nourishment  and  being  en- 
tirely without  abdominal  symptoms,  when  suddenly  he  became  un- 


PULMONARY   EMBOLISM  315 

able  to  get  his  breath,  dropped  back  deeply  cyanosed,  and  died  in  a 
few  minutes. 

10.  Hysterectomy  for  carcinoma.  Ten  days  after  the  complete 
Wertheim  operation  this  lady  was  sitting  up  in  bed,  having  just  par- 
taken of  a  light  lunch  and  being  without  abdominal  symptoms,  when 
suddenly  she  began  to  breathe  with  difficulty,  extremities  became 
cold,  every  evidence  of  extreme  shock  appeared,  and  in  11  hours  she 
was  dead. 

11.  Umbilical  herniotomy.  Eight  days  after  this  operation  on  a 
lady  fifty-two  years  of  age,  there  was  a  sudden  onset  of  the  typical 
symptoms  which  have  characterized  the  cases  just  related.  However, 
under  stimulation  treatment  the  patient  gradually  began  to  breathe 
more  easily,  and  in  twenty-four  hours  seemed  out  of  immediate  dan- 
ger. She  continued  to  improve,  left  the  hospital  a  month  later,  and 
has  remained  well  for  several  years. 

12.  Appendectomy.  This  was  an  interval  operation,  being  ex- 
tremely difficult  on  account  of  location  of  the  appendix  and  adhe- 
sion surrounding  it.  There  were  no  symptoms  up  to  the  ninth  day, 
when  patient  got  up  for  the  first  time,  suddenly  manifested  intense 
cyanosis  and  breathlessness,  became  unconscious  and  was  dead  in  a 
few  minutes. 

13.  Intestinal  resection.  Two  clays  after  operation  on  this  man  of 
fifty-four,  in  whom  no  postoperative  symptoms  had  appeared,  he  was 
conversing  with  me  when  suddenly  he  gasped  for  breath,  became 
blue,  then  unconscious,  and  was  dead  in  five  minutes.  A  knife  which 
happened  to  be  handy,  was  plunged  into  his  trachea  and  artificial  res- 
piration maintained  for  a  protracted  period.  The  fact  that  this 
measure  was  without  avail  seems  proof  of  the  fact  that  this  suffoca- 
tion can  be  regarded  only  as  having  been  due  to  the  sudden  interrup- 
tion of  the  oxygen-carrying  blood  stream. 

14.  Operation  for  varicose  veins  of  leg.  A  lady  forty-seven  years 
of  age  had  experienced  the  combined  Mayo  vein  stripping  and  the 
Schede  ligation  on  the  lower  extremity.  The  evening  following  the 
operation  she  suddenly  experienced  all  the  typical  symptoms  of  pul- 
monary embolism,  which  then  rapidly  disappeared;  she  then  made 
a  protracted,  but  otherwise  uneventful  recovery.  It  seemed  prob- 
able to  the  experienced  clinicians  who  saw  her  that  this  was,  in  view 
of  the  nature  of  the  operation,  in  great  probability  a  case  of  pul- 
monary embolism. 

Symptoms. — It  may  be  of  value  in  these  14  surgical  cases  to  note 
the  interval  of  time  that  elapsed  after  the  operation  or  injury  before 
the  onset  of  pulmonary  symptoms.     In  these  instances  this  period 


316  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

was  as  follows:  1,  one  day;  1,  tAvo  days;  1,  three  days;  1,  six 
days;  4,  eight  days;  2.  nine  days;  1,  eleven  days;  1,  thirteen  days; 
1,  fifteen  days;  1  twenty-eight  days.  An  average  shows  that  a 
little  less  than  seven  days  intervened  as  a  rule  between  the  time 
of  operation  or  injury  and  the  lodgment  of  the  blood  clot  in  the 
pulmonary  artery.  It  should  be  noted  that  in  those  eases  where 
embolism  occurred  a  few  days  after  operation,  the  condition  was 
such  that  thrombosis  may  have  been  present  some  time  before  it 
was  performed. 

Twelve  of  the  14  cases  resulted  fatally.  In  this  connection  it  is 
interesting  to  note  the  time  intervening  between  the  onset  of  symp- 
toms and  the  occurrence  of  death  in  these  and  in  six  other  cases 
known  to  me.  This  is  given  in  each  instance  as  found  in  the  hospital 
records:  3  suddenly  or  instantly;  1  almost  instantly;  1  in  a  few 
minutes;  3,  five  minutes;  2.  ten  minutes:  1.  fifteen  minutes;  4.  thirty 
minutes;  1.  two  hours;  1.  five  hours;  1.  eleven  hours;  and  2.  twelve 
hours. 

So  far  as  the  symptoms  of  thrombosis  preceding  pulmonary  em- 
bolism are  concerned.  Lotheisen  has  very  properly  remarked  that 
they  very  often  fail  entirely.  Schachtler,  however,  has  made  some 
very  interesting  observations  which  may  be  of  value  in  this  connec- 
tion. He  had  the  opportunity  of  studying  seven  cases  at  Zurich,  and 
noticed  that  the  temperature  remained  normal  in  all  of  them,  while 
the  pulse  gradually  rose  in  a  step-like  manner  until  the  lung  symp- 
toms became  manifest.  He  refers  to  this  change  in  the  pulse  as  a 
prodromal  symptom  indicative  of  thrombus  formation. 

The  symptoms  of  pulmonary  embolism  itself  can  not  fail  to  be 
burned  into  the  memory  of  one  who  has  ever  seen  a  patient  die  as  a 
result  of  this  accident.  A  seemingly  normal  individual  suddenly 
becomes  breathless,  cyanotic,  anxious,  resiles,  complains  of  pain  and 
oppression  in  the  chest,  the  pupils  grow  wide,  cold  sweat  pours  out 
and  unconsciousness  quickly  supervenes.  The  pulse  in  many  in- 
stances becomes  rapid  and  irregular  to  the  point  where  it  can  not  be 
counted  at  all.  In  one  case  which  we  have  mentioned  we  had  appar- 
ent complete  blocking  of  the  main  trunk  where  symptoms  of  complete 
suffocation  suddenly  appeared.  The  pulse,  as  might  always  be  ex- 
pected when  air  is  instantly  cut  off.  became  slower  and  less  compres- 
sible, the  symptoms  in  general  being  analogous  to  those  when  one  of 
the  main  branches  of  the  pulmonary  artery  is  ligated  in  a  dog.  The 
rapid  overdistension  of  the  right  ventricle  which  ensues  is  accom- 
panied by  a  lowering  of  arterial  blood  pressure  and  by  a  tremendous 
rise  of  venous  pressure.     This,  of  course,  follows  the  initial  rise  in 


PULMONARY   EMBOLISM  317 

arterial  pressure.  Whether  cyanosis,  dyspnea,  and  failing  pulse  are 
referable  to  cerebral  anemia  or  to  interference  with  coronary  cir- 
culation, or  to  both  together,  is,  according  to  Welch,  neither  easy  nor 
important  to  determine. 

Treatment. — Unfortunately  the  treatment  of  such  conditions  must 
be  largely  of  a  preventive  nature.  In  order  to  prevent  just  such  ac- 
cidents, Mueller  cites  cases  in  which  he  ligated  quite  a  number  of 
varicose  veins  of  the  lower  extremity,  while  Kramer  split  varicose 
saphenous  veins  in  50  instances  and  evacuated  thrombi  to  prevent 
pulmonary  embolism,  as  well  as  to  combat  the  local  effects  of  the 
disease.  He  states  that  he  was  successful  in  every  instance.  Becker 
advises  the  removal  of  the  saphenous  vein  when  the  thrombus  has 
not  extended  into  the  femoral. 

It  is  perfectly  obvious  that  superficial  varicose  areas  should  be 
subjected  to  no  manipulation  during  the  postoperative  convalescence. 
One  might  go  farther,  indeed,  and  urge  that  they  be  kept  carefully 
protected  in  order  to  avoid  the  misfortune  which  attended  the  knee 
joint  massage  alluded  to  above.  My  own  suggestion,  prompted  by 
more  than  one  of  the  cases  above  recorded,  relates  to  varicose  veins 
in  the  vicinity  of  abdominal  tumors.  Not  infrequently  are  these 
seen  in  the  female  pelvis,  especially  in  connection  with  myomata  of 
the  uterus.  They  should,  if  possible,  be  extirpated  with  the  growth, 
or  at  least  ligated  as  far  out  as  possible  toward  the  pelvic  wall,  to 
avoid  the  likelihood  of  thrombosis  (should  they  be  left  behind)  with 
a  subsequent  fatal  accident  of  the  most  distressing  nature. 

Given  a  patient  in  whom  unduly  large  diseased  veins  have  been 
found  at  operation,  and  who  hence  is  supposed  to  present  a  predis- 
position to  embolism,  it  is  not  going  too  far  to  urge  that  such  an  one 
should  not  be  allowed  any  undue  exertion  for  at  least  a  week.  There 
should,  as  a  matter  of  course,  be  the  least  possible  increase  in  the 
abdominal  tension  necessary  to  empty  the  intestinal  tract,  the  genito- 
urinary tract,  and  the  respiratory  apparatus,  while  the  patient  should 
be  warned  against  sudden  violent  movements  of  any  kind  through 
nervous  unrest. 

Some  authors  advise  that  the  patient  be  got  out  of  bed  early,  that 
the  bowels  be  kept  open,  that  respiratory  exercises  be  indulged  in, 
and  that  preliminary  heart  stimulation  be  undertaken. 

So  much  for  prevention.  Should  the  accident  happen,  a  very 
strong  heart  may  tide  over  an  individual  in  whom  only  one  branch 
of  the  artery  is  occluded,  and  consequently  the  opinion  is  general 
that  every  heart  should  be  aided  as  much  as  possible  by  stimulation. 
However,  not  much  is  to  be  expected  in  many  instances. 


318  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

The  patient  must  be  elevated  so  that  respiration  be  favored,  plenty 
of  fresh  air  or  even  oxygen  should  be  exhibited,  and  artificial  respira- 
tion has  been  suggested.  (One  fails  to  see,  however,  the  logic  of 
this  latter.)  The  patient  is  to  be  encouraged,  reassured,  and  if 
possible  kept  from  the  panic  which  rapidly  wears  out  an  overdis- 
tended,  overworked  and  dilating  heart.  Atropine  has  been  suggested. 
Counterirritation  by  rubbing  over  the  posterior  pulmonary  area  may 
have  some  effect  in  keeping  down  pulmonary  edema.  Osier  injects 
camphor  oil  and  ether  every  half  hour,  then  follows  this  with 
atropine.  If  the  patient  lives  three  hours,  he  states  that  stimulation 
with  strophanthus,  or  other  similar  drills,  may  lie  indulged  in.  The 
calcium  salts  and  other  substances  intended  to  increase  the  coagula- 
bility of  the  blood  are  of  course  to  be  avoided.  Bidwell  has  warned 
against  magnesium  carbonate,  milk,  etc.,  for  this  reason. 

Trendelenburg's  experiment  of  removing  a  pulmonary  thrombus 
from  the  living  human  subject  is  too  well  known  to  deserve  more 
than  passing  mention  here.  In  describing  the  technic  in  his  "Tech- 
nik  der  Thoraxchirurgie, "  Sauerbruch  writes  that  not  one  of  the 
several  upon  whom  it  was  done  at  Leipzig  lived.  Still  he  thinks 
such  a  desirable  outcome  possible  in  the  future. 

Bibliography 

Albanus:     Beitr.  z.  klin.  Chir.,  si. 

Bartlett  and  Thompson:     Ann.  Surg.,  May,  1908. 

■  :     Berl.  klin.  Wchnschr.,  1907,  No.  39,  p.  1262. 
Gussenbauer:      V'irchow's  Arch.,  exxxii,  •"■•'!•". 
Koenig:     Berl.  klin.  Wchnschr.,  1907,  No.  39,  p.  1262. 
Kramer:      Zentralbl.  f.  Chir.,    L901,  p.  37. 
Leichtenstem :     Mtinehen   med.   Wchnschr.,    1899,    No.  48. 
Lotheiscn:     Beitr.  z.  klin.  Chir.,  xxxii,  Part  li. 
Lubarsch:     Allg.  Path.,  i.  211. 
Mueller:      Arch,   f.  klin.  Chir.,  lxvi,  642. 
Mynter:     Ret".    Welch:     Lee.  cit. 
Quenste.lt:     Ref.  Lubarsch.  Allg.  Path.,  Wiesbaden,   ' 
Robinson:      Med.   Rec,   New   York,  Jan.   14.    1905. 
Sachachtler:     Inaug.  Diss.,  Zurich,  1895.     (Ref.) 

Sonnenburg:     :;i   Versammlung,  4.  deutsche  Gesellschaft  f.  Chirurgie. 
Virchow:     Gesammelte  Abhandlungen,  Frankfurt  a.  M.,   L856. 
Welch:     Allbutt  's  System  of  Medicine,  vi,  194. 


CHAPTER  XXXIX 

PYLEPHLEBITIS 

By  0.  F.  ^IcKittriek.  St.  Louis,  Mo. 

The  significance  of  thrombosis  and  embolism  in  other  parts  of  the 
body  depends  entirely  upon  the  location  and  extent  of  the  affection. 

Pylephlebitis:  Inflammation  of  the  portal  vein,  with,  subsequent 
abscess  formation  of  the  liver  while  not  a  frequent  occurrence  fol- 
lowing operations,  too  often  complicates  a  surgical  convalescence, 
particularly  one  in  which  the  appendix  and  rectum  have  been  in- 
volved, to  receive  other  than  careful  attention.  Probably  the 
first  ease  recorded  in  literature,  according  to  Loison,1  was  described 
by  Waller  in  1846.  A  short  time  thereafter  Hilliaret  reported  an 
ascending  infection  of  the  hepatic  veins  from  an  ileocecal  abscess, 
and  from  this  same  source  infection  of  the  liver  occurred  in  a  case 
reported  by  Buhl  in  1854.  Of  late  years  C4erster2  and  Munro3  each 
reported  9  cases  following  appendicitis,  while  Hart4  collected  17 
cases  of  liver  abscess  due  to  pylephlebitis,  3  of  which  were  attrib- 
uted to  affections  of  the  appendix.  Beer,3  adds  another  case  to  the 
list  as  a  consequence  of  gangrenous  appendicitis.  Enderlen6  col- 
lected 6  cases  of  thrombosis  of  the  portal  vein  as  a  result  of  blunt 
force  being  applied  to  the  abdomen,  and  in  addition,  described  one 
of  his  own. 

The  condition  most  frequently  follows  appendicitis,  but  it  may 
occur  after  other  operations  especially  those  about  the  rectum  in 
the  presence  of  infected  hemorrhoids.  The  origin  of  this  dire  mal- 
ady occurring  after  appendectomies  or  hemorrhoidal  operations  is 
not  so  surprising  when  it  is  considered  that  thrombosis  of  the 
veins  in  these  regions  (Fig.  48A)  is  a  part  of  the  inflammatory  proc- 
ess; and  when  a  portion  of  a  thrombus  is  dislodged  it  has  a  direct 
course  to  the  portal  system  (Fig.  48B),  through  the  appendiceal  veins 
emptying  into  the  superior  mesenteric,  in  the  former  case ;  and 
through  the  superior  hemorrhoidal,  the  inferior  mesenteric,  the 
splenic,  and  the  portal  vein  in  the  latter  case.  However,  it  does 
seem  strange  that  it  should  occur  just  as  often  in  clean  and  simple 
cases  as  in  those  of  the  most  virulent  type.7  It  also  matters  very 
little  whether  the  operation  is  performed  during  an  acute  attack, 
in  the  interval,  or  in  the  presence  of  abscess  formation. 

319 


320 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


The  original  thrombus  is  usually  located  in  the  lower  part  of  the 
portal   vein,    though    thrombi   may   be    scattered    along-   the    whole 


Fig.   48-A. — The  many   tributaries   of   the  portal  vein.      (After   Spalteholz.) 

course  of  the  vessels  to  the  primary  point  of  inflammation.  Em- 
boli originating  from  these  thrombi  pass  further  along  the  course 
of  the  vessel  and  lodging  in  its  finer  branches  form  secondary  ab- 


PYLEPHLEBITIS 


321 


scesses  throughout  the  liver.  Unfortunately,  these  abscesses  are 
multiple  and  seem  to  show  a  preference  for  the  anterior  surface 
of  the  liver. 

Pylephlebitis,  as  stated,  elsewhere,  is  ushered  in  with  chills  fol- 
lowed by  high  fever  and  pain  which  is  usually  severe,  and  more  or 
less' generalized  over  the  right  hypochondrium.  Soon  thereafter  the 
patient  may  become  icteric.  In  Beer's  case  all  of  these  symptoms 
appeared  within  24  hours  after  the  operation.  The  blood  culture 
taken  at  the  beginning  of  the  symptoms  showed  streptococci;  while 
the  leucocytes  were  18,000,  the  polynuelears  being  91  per  cent. 
The  physical  examination  in  most  of  these  eases  will  reveal  pain  and 


Fig.   48-B. — The  portal  vein.      (After   Spalteholz.) 

tenderness  along  the  right  border  of  the  right  rectus  muscle  and  a 
tender,  uniformly  enlarged  liver  and  spleen.  The  course  of  the 
disease  is  usually  very  rapid;  but  if  life  is  prolonged  a  few  days, 
the  patient  will  show  marked  emaciation. 

Treatment. — The  only  possible  treatment  is  surgical.  There  are 
no  preventive  measures,  unless  the  admonition  of  Gerster5  is  ob- 
served that  undue  traumatism  to  the  tissues  during  operation  be 
avoided.  Prompt  surgical  interference  in  cases  of  appendicitis  or 
infected  hemorrhoids  may  be  a  step  toward  diminishng  the  in- 
stance of  this  disease. 


322  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

As  yet  no  definite  surgical  procedure  has  developed  for  this  con- 
dition. For  more  than  half  a  century  men  have  experimented  in 
an  effort  to  find  a  method  of  treatment  which  would  effectually 
combat  the  ravages  of  these  infections.  Ore9  in  1856  ligated  the 
portal  vein  in  rabbits  resulting  in  death  of  the  animals  in  a  very  short 
time.  Later  on  Schiff,10  Claude  Bernard,11  and  others  showed  very 
conclusively  that  portal  vein  ligation  in  dogs  caused  death  within 
three  hours.  Kusnetzow12  thought  that  ligation  of  the  vein  at  a  level 
other  than  the  ones  which  had  been  employed  before  might  prove 
compatible  with  life.  His  idea  was  soon  borne  out  by  his  experi- 
ment showing  that  dogs  may  live  if  the  portal  vein  is  occluded 
above  the  gastrosplenic.  His  work  unfortunately  could  not  be 
confirmed  b\r  others  including  Ito  and  Omi,13  and  Neuhof.14  It 
never  occurred  to  any  one  that  the  portal  vein  could  be  occluded 
by  ligating  its  branches  at  different  times  without  producing  death 
of  the  animal,  until  Solowieff13  appeared  upon  the  scene.  His  work 
has  been  shown  to  be  correct  by  Neuhof.  The  latter  ligated  the 
inferior  mesenteric,  superior  mesenteric,  splenic,  and  finally  the 
portal  veins  in  each  animal  during  different  operations,  and  found 
that  the  dogs  in  every  instance  lived  and  enjoyed  good  health.  The 
animals  sacrificed  and  examined  showed  in  each  case  a  well-developed 
collateral  circulation  coursing  within  the  gastrohepatic  omentum  from 
the  region  of  the  stomach  to  that  of  the  attachment  to  the  liver. 
The  liver  was  found  to  be  normal  in  every  way  after  the  final  liga- 
tion of  the  portal  vein. 

Other  experiments  were  carried  out  by  Neuhof  in  which  he  grad- 
ually occluded  the  portal  vein  itself,  a  number  of  operations  ex- 
tending over  several  days  in  each  case  being  done,  and  found  that 
his  results  were  in  accord  with  those  above. 

The  outcome  of  these  experiments  is  not  astounding  since  it  has 
been  known  for  some  time  that  the  portal  vein  may  become  oc- 
cluded in  the  human  being  without  subsequent  death.  In  fact, 
Bartlett  packed  it  full  of  gauze  after  accidental  injury  during  a  com- 
mon duct  operation,  no  ill-effect  being  observed  in  consequence. 
Gintrac16  in  1857  collected  6  cases  of  portal  occlusion  in  the  human 
subject,  and  since  this  time  many  cases  have  been  placed  on  rec- 
ord. Some  of  the  patients  lived  as  long  as  thirty  years.  The  re- 
sulting anastomotic  circle  caused  by  the  cessation  of  blood  flow 
through  the  portal  vein  was  considered,  and  rightly  so,  the  same  as 
in  cases  of  cirrhosis  of  the  liver,  but  in  addition,  Pick17  has  recently 
shown  that  the  newly  formed  gastrohepatic  anastomosis  is  very 
efficient  in  carrying  blood  to  the  liver.    Umberls  reported  a  case  in 


PYLEPHLEBITIS  323 

which  the  adhesions,  following  portal  vein  occlusion,  carried  ves- 
sels which  took  the  place  of  the  regular  gastrohepatic  anastomosis. 

By  experimentation  then,  it  has  been  shown  that  the  portal  vein 
can  be  ligated  without  ill  results  to  the  subject,  and  that  a  collat- 
eral circulation  rapidly  develops  in  the  gastrohepatic  omentum. 
Therefore,  Neuhof  strongly  recommended  this  procedure  in  suppu- 
rative pylephlebitis,  and  in  view  of  the  fact  that  the  condition  al- 
most invariably  ends  fatally  it  seems  to  us  justifiable  to  use  any 
procedure  which  offers  any  measure  of  hope.  While  some  of  the 
cases  run  a  very  rapid  course,  some  patients  live  weeks  and  even 
months.14  In  the  latter  cases  the  postmortem  has  shown  collateral 
circulation  to  have  been  established  with  the  portal  vein  completely 
occluded.  Multiple  abscesses  inevitably  follow  such  a  condition 
and  this  is  another  reason  for  ligation,  since  such  a  procedure  will 
cut  off  the  source  of  the  hepatic  infection. 

The  technic  of  the  operation  as  done  by  Neuhof  is  briefly  as  fol- 
lows :  A  curved  incision  starting  near  the  lower  end  of  the  ster- 
num, running  parallel  with  the  right  free  border  of  the  ribs  de- 
scends vertically  for  5  cm.  The  upper  part  of  the  right  rectus  muscle 
is  then  divided  transversely.  The  margin  of  the  liver  is  elevated, 
and  the  pyloric  end  of  the  stomach  drawn  downwards.  The  re- 
gion of  the  portal  vein  is  thereby  brought  into  view,  no  further 
dissection  being  necessary.  The  vein  itself  is  sufficiently  exposed 
by  incising  the  thin  layer  of  overlying  peritoneum.  It  can  now  be 
gently  freed  from  the  surrounding  structures  and  readily  ligated 
above  the  entrance  of  the  gastrosplenic  vein. 

In  cases  where  operation  is  decided  upon  very  soon  after  the  oc- 
currence of  this  complication,  the  vein  should  be  gradually  oc- 
cluded. Whether  this  is  to  be  done  by  ligation  of  the  branches  as 
above  mentioned  or  by  gradual  compression  of  the  vein  itself  by 
means  of  a  clamp,  must  be  determined  by  the  surgeon  himself. 
On  the  other  hand  if  there  is  reason  to  believe  that  time  has  elapsed 
sufficient  to  bring  about  collateral  anastomosis,  the  vein  should  be 
immediately  ligated.  As  to  the  point  of  election  Neuhof  would 
ligate  above  the  highest  portion  involved  if  this  was  surgically  ac- 
cessible. In  every  instance  surgical  occlusion  of  the  portal  vein 
should  be  combined  with  an  omentopexy  in  order  to  assist  the  al- 
ready forming  collateral  circulation.  According  to  Gerster19  the 
pus  in  the  vein  may  be  drained  if  the  blood  stream  has  been  suffi- 
ciently side-tracked. 

In  the  case  reported  by  Beer  an  omentopexy  was  done  three 
days  after  the  symptoms  of  pylephlebitis  had  developed.     Neither 


324  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

the  two  mesenteric  nor  the  splenic  veins  being  easily  accessible,  li- 
gation was  not  attempted.  After  three  clays  the  portal  vein  was 
ligated.  The  patient  died  within  forty-eight  hours,  but  death  was 
apparently  due  to  a  septicemia,  streptococci  and  colon  bacilli  being 
the  infective  agents.  No  signs  or  symptoms  referable  to  occlusion 
of  the  portal  system  were  in  evidence  following  the  operation. 

Bibliography 

iLoison:     Eev.  de  chir.,  1900,  xxi,  -122. 

zGerster:     Med.  Eec,  New  York,  June  27,  1903. 

3Munro:     Boston  Med.  and  Surg.  Jour.,  Jan.  23,  1902,  p.  81. 

4Hart:     Presb.  Hosp.  Rep.   (N.  Y.),  1900,  p.  157. 

sBeer:     Am.  Jour.  Med.  Sc,  1915,  cl,  548. 

eEnderlen:     Beitr.  z.  klin.  chir.,  1913,  lxxxiii,  726. 

?Frazier:     Keen's  Surgery,   1906,  i.  441. 

sGerster:      Med.  Eec.  New  York.  June  27,  1903. 

sOre:     Compt.  rend.  Acad.  d.  Sc.  iii. 
loSchiff:     Zentralbl.  f.  d.  med.  Wissensch.,  Berlin,  1S63,  No.  8. 
nClaude  Bernard:     Lecons  sur  le  diabete  et  la  Giyeogenese  Animals,  Paris,  1877. 
izKusnetzow:     Russk.  Vraeh.,  1900,  Nos.  32  and  33. 
islto  and  Omi:     Deutseh.  Ztschr.  f.  Chir.,  1901-2,  No.  62. 
"Neuhof:     Surg.  Gynec.  and  Ol.st.,  191:;.  xvi,  484. 
isSolowieff:      Virehows  Arch.  f.  path.  Anat.,  1875,  lxii. 
icSclimorl:     Jahrb.,  xciii. 

i"Pick:     Virehows  Arch.  f.  path.  Anat.,  cxevii. 
lsTJmber:     Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,   L901,  vii. 
loGerster:     Tr.  Am.  Surg.  Assn.,  Phila.,  1903. 


CHAPTER  XL 

SKIN  ERUPTIONS 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

Cutaneous  eruptions  at  times  follow  surgical  operations.  The 
surgical  interference  may  be  the  direct  cause  of  these  eruptions 
but  usually  other  factors  which  present  themselves  during  the  con- 
valescence are  responsible.  Recently  McCarty1  has  observed  that 
out  of  every  1000  consecutive  operative  cases,  43  showed  some  sort 
of  skin  disturbance.  He  found  that  the  lesions  were  of  two  types, 
the  first  appearing  within  24  to  48  hours  after  the  operation  and  the 
second  appearing  after  a  longer  period. 

"The  earlier  cases  were  characterized  by  a  mild  erythematous  or 
papular  eruption  of  general  distribution,  with  no  systemic  dis- 
turbance and  little  elevation  of  temperature.  Itching  was  marked 
from  the  beginning  and  the  face  was  involved  in  every  instance. 

"In  the  other  class  of  cases  the  eruption  appeared  suddenly  three 
or  more  days  after  operation.  During  the  interval  there  was  no 
prodroma,  but  the  temperature  continued  higher  than  in  normal 
convalescence  and  the  blood  showed  a  moderate  leucocytosis.  The 
condition  varied  from  a  localized  to  an  almost  continuous  eruption  and 
in  some  cases  at  first  resembled  scarlet  fever  or  measles.  It  began  as 
an  erythematous  or  fine  papular  eruption  located  at  first  on  the  in- 
ner surfaces  of  the  forearms  and  thighs  and  extending  over  the 
whole  body,  rarely  affecting  the  face  and  never  involving  the  palms 
and  soles.  It  was  accompanied  with  marked  itching  which  per- 
sisted until  fading  occurred.  The  papules  were  at  first  pink  and 
later  dark  red  with  a  tendency  toward  coalescence  over  the  bony 
parts,  and  the  eruption  reached  its  height  in  24  to  36  hours,  after 
which  it  began  to  subside.  The  onset  occurred  as  late  as  7  days 
after  the  operation  and  the  condition  persisted  from  one  to  seven 
days.     Desquamation  was  not  observed  in  any  case. 

"The  temperature  showed  an  elevation  of  about  one-half  degree 
above  that  of  a  normal  convalescence  and  this  elevation  continued 
until  the  eruption  had  disappeared.  The  daily  leucocyte  count  was 
14,000  until  the  eruption  had  faded. ' ' 

In  all  the  cases  in  his  series,  ether  was  the  anesthetic  employed, 
but  cases  have  been  reported  by  others  where  nitrous   oxide   and 

325 


326  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

chloroform  have  been  used.  Catharsis,  enemata,  or  drugs  seemed 
to  have  no  influence  and  there  was  no  definite  relation  to  men- 
struation. 

The  condition  seems  to  be  due  to  a  combination  of  factors,  there 
being  in  each  case  an  immediate  cause,  a  certain  individual  idio- 
syncrasy and  an  underlying  nervous  susceptibility. 

The  immediate  cause  takes  the  form  of  mechanical  irritation, 
such  as  operative  shock,  enemata,  or  drugs,  and  the  underlying 
cause  acts  probably  as  a  vasomotor  disturbance  due  to  irritation 
of  sympathetic  nerve  fibers. 

Ether  Rash. — During  etherization,  Probyn  and  Williams2  have 
stated  that  a  rash  may  occur,  especially  in  women  and  children, 
which  usually  appears  just  as  the  patient  is  becoming  comatose  and 
takes  the  form  of  an  erythema  which  occurs  most  frequently  on 
the  neck  and  shoulders,  but  the  chest,  abdomen,  and  even  the 
thighs  may  become  involved.  Profuse  sweating  frequently  accom- 
panies the  rash  and  lasts  about  ten  minutes.  Buxton3  and  others 
state  this  phenomena  is  due  to  the  action  of  the  ether  on  the  cen- 
tral nervous  system. 

Septic  Rash. — At  times  there  appears  a  general  erythema  resem- 
bling that  of  scarlet  fever,  or  the  skin  complication  may  take  the 
form  of  an  urticaria  and  become  pustular  or  hemorrhagic,  fol- 
lowed in  a  few  days  by  desquamation.  It  may  be  associated  with 
septicemia  and  pyemia,  or  occur  within  the  course  of  a  few  hours 
following  the  symptoms  of  such  general  infections.  Frequently  in 
children  an  erythema  occurs  in  the  upper  half  of  the  body  in  con- 
junction with  suppuration.  It  is  usually  ushered  in  by  a  few  hours 
of  malaise,  restlessness,  high  temperature,  and  fast  pulse.  Fre- 
quently a  leucocytosis  is  present.  "Within  4  or  5  days  the  eruption 
fades  and  unless  it  has  been  very  severe  no  desquamation  follows. 

There  is  described  by  several  writers  a  condition  known  as  ery- 
thema scarlatiniforme  which  occurs  after  operations.  This  con- 
dition which  was  first  described  by  Hardy  is  characterized  by  le- 
sions which  vary  from  a  localized  erythema,  to  a  general  scarlati- 
nous eruption.  The  symptoms  range  from  none  at  all  to  the  most 
severe  grade  of  constitutional  disturbance.  With  the  appearance 
of  the  skin  lesions  the  constitutional  symptoms  usually  subside 
and  within  one  to  four  days  the  eruption  begins  to  abate  and  a 
fine,  almost  imperceptible  desquamation  follows.  The  whole  proc- 
ess  takes  from  about  ten  days  to  four  weeks. 

The  treatment  in  these  cases  concerns  itself  with  elimination. 
The  ease  should  always  be  isolated,  but  not  exposed  to  other  infec- 


SKIN   ERUPTIONS  327 

tious  diseases.  Most  authors  advise  a  zinc  oxide  and  starch  powder 
to  be  applied:  other  palliative  measures  are  carried  out  to  relieve 
any  discomfort. 

True  scarlet  fever  has  been  reported  too  often  not  to  mention  it 
a  serious  complication  in  these  cases.  Eeeently  Roberts4  reported 
four  cases  in  which  the  diagnosis  was  made  by  many  men  skilled 
in  this  particular  disease  which  makes  the  fact  all  the  more  inter- 
esting. Many  observers  believe  this  communicable  condition  is  a  mere 
coincidence,  while  others  think  it  is  due  to  the  increased  suscepti- 
bility caused  by  the  shock  of  the  operation,  by  the  wound,  or 
burn,  etc.  The  malady  occurs  most  frequently  in  children.  The 
eruption  is  usually  typical  and  is  followed  by  desquamation.  It  is 
not  at  all  unlikely  that  in  patients  who  have  had  recurrent  attacks 
of  appendicitis  for  instance,  the  presence  of  an  undetected  scarlet 
fever  in  its  incubation  stage  may  stir  up  acute  appendiceal  symp- 
toms and  cause  the  surgeon  to  operate.  The  eruption  appearing  in 
a  day  or  so  later  would  then  be  considered  a  surgical  scarlet  fever. 
The  treatment  of  scarlet  fever  under  such  circumstances  is  that  or- 
dinarily described  in  textbooks  on  medicine. 

A  condition  that  is  frequently  seen  follows  surgical  procedures 
under  unclean  conditions ;  such  as  incisions  for  drainage  of  pus 
wherever  located,  around  abdominal  drainage,  tubes,  infected 
wounds,  etc.  It  is  called  infectious  eczematoid  dermatitis  and  is 
due  to  infection  of  the  skin  follicles  by  the  pus  organisms.  It  be- 
gins insidiously  around  the  edges  of  wounds  and  may  spread  over 
very  large  areas  and  even  involve  parts  of  the  skin  at  a  distance. 
The  characteristic  lesions  are  tiny  follicular  pustules  which  quickly 
aggregate  to  form  patches.  There  is  considerable  itching,  and 
secondary  lesions  due  to  scratching  quickly  make  their  appearance. 

The  treatment  is  the  use  of  mild  antiseptics  in  ointment  form. 
Three  per  cent  xeroform  in  petrolatum  is  a  very  good  application. 
One  per  cent  ammoniated  mercury  ointment  or  two  to  four  per  cent 
ichthyol  are  also  efficacious  agents.  The  condition  is  sometimes 
very  severe,  covers  very  large  areas  of  the  skin,  and  is  highly  re- 
sistant to  treatment.  Under  such  circumstances  the  use  of  staphy- 
lococcus vaccine  will  produce  good  results. 

Food  as  an  etiologic  factor  in  producing  skin  lesions,  such  as 
erythema  and  urticaria  is  well  known.  In  many  instances  they  are 
apparently  produced  by  so-called  indigestion,5  but  idiosyncrasy  per- 
haps plays  an  important  role.  Inability  to  digest  the  starchy  foods 
is  noted  in  some  of  these  cases. 

An  improper  diet,6  either  too  much  or  too  little  food,  can  be  con- 


328  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

sidered  a  factor  in  many  skin  lesions  but  whether  it  acts  directly 
or  indirectly  has  not  been  determined.  Eruptions  following  the 
ingestion  of  strawberries,  buckwheat,  and  oatmeal  have  been  noted. 
Particularly  have  they  been  seen  after  the  ingestion  of  foods  and 
condiments  which  are  difficult  of  digestion  or  are  too  stimulating 
such  as  pastries,  cheese,  veal,  spices,  mustard,  pepper  and  pickles. 
Foods  which  easily  undergo  decomposition,  such  as  pork,  oysters, 
lobsters,  fish,  crabs  and  clams,  are  always  to  be  considered  as  pos- 
sible causes. 

While  such  food  is  not  allowed  in  the  early  postoperative  treat- 
ment and  therefore  does  not  enter  as  a  factor,  later  on  in  the  con- 
valescence it  becomes  a  very  important  question  and  a  knowledge 
of  the  baneful  influences  of  such  foods  will  often  prevent  an  un- 
pleasant complication. 

A  toxic  erythematous  rash  other  than  that  produced  by  food  has 
been  noted  following  sudden  changes  in  the  weather,  in  cases 
where  the  patient  was  exposed  to  cold  or  to  a  chilling  wind.  Ab- 
sorption of  secretion  and  of  aseptic  material  from  wounds  is  fol- 
lowed by  toxic  rashes  at  times.  The  eruption  appears  without  pro- 
dromal symptoms  within  48  hours  after  the  exposure  or  operation. 
It  occurs  in  patches  and  usually  involves  only  the  body  and  ex- 
tremities and  disappears  in  about  24  hours.  In  children,  however, 
there  may  be  a  marked  febrile  reaction  with  gastric  symptoms,  de- 
lirium, and  even  coma.  Crawford,7  Shepherd8  and  others  have 
noted  such  a  condition  following  soapsuds  enemas,  in  which  the 
ordinary  yellow  soap  was  used.  Shepherd  was  able  to  diminish 
the  eruptions  in  his  patients  by  using  castile  soap  instead,  lie  con- 
cluded the  resin  in  the  soap  produced  the  skin  lesions.  Other  ob- 
servers think  the  irritation  alone  is  the  causative  factor  as  the  erup- 
tions occur  following  enemas  of  any  kind. 

The  treatment  is  directed  above  the  line  of  relieving  the  cause  and 
is  chiefly  palliative. 

Drugs  have  long  been  known  to  produce  various  kinds  of  skin 
eruptions.  The  symptoms  produced  by  medicinal  agents  constitute 
the  symptomatology  of  the  various  erythematous,  exudative,  and 
inflammatory  diseases."  The  eruptions  may  occur  somewhat  sud- 
denly following  a  dose  or  so  of  the  drug,  and  again  the  lesions  may 
occur  only  after  continued  use  of  the  inciting  medicinal  agent.  At 
times  the  eruption  does  not  occur  until  after  the  drug  has  been 
withdrawn.  Usually  a  withdrawal  of  it  prevents  a  continuance 
of  the  symptoms,  though,  as  in  the  case  of  bromides  and  iodides, 
particularly  in  children,  the  lesions  may  be  present  for  some  time. 


SKIN   ERUPTIONS  329 

According  to  most  observers  the  eruption  in  the  majority  of  cases 
is  due  to  an  idiosyncrasy  of  the  patient  to  that  particular  drug. 
The  same  type  of  lesion  is  usually  produced  in  the  same  patient 
though  this  does  not  always  follow.  Women  and  children  are  most 
frequently  affected  and  it  seems  that  blondes  are  more  susceptible 
than  brunettes. 

Just  how  drug  eruptions  are  produced  has  been  the  object  of 
much  investigation.  The  theory  that  the  drug  causes  the  irrita- 
tion as  it  is  being  eliminated  by  the  skin  has  been  proved  untrue. 
Behrend  believes  that  the  drug  generates  some  toxin  in  the  blood 
to  which  the  eruptive  condition  is  due.  Engman  and  Mook10  do 
not  directly  support  such  a  view,  but  partially  confirm  the  hypoth- 
esis. Investigations  have  shown  that  in  skin  lesions  caused  by 
iodides  and  bromides  especially,  the  drug  circulates  in  the  blood  and 
under  certain  conditions,  acts  as  a  toxin.  The  chief  change  which 
it  produces  in  the  skin  is  a  slight  deposit  of  cellular  elements  about 
the  blood  vessels.  This  is  best  seen  in  the  apparently  normal  skin 
and  in  the  absence  of  gross  lesions.  It  has  also  been  noted  that  the 
worst  lesions  are  seen  in  those  patients  who  present  heart  or  kid- 
ney disease  or  both.  Morrow11  thinks  the  lesions  are  the  result 
of  the  action  of  the  drug  upon  the  vasomotor  centers  or  upon  the 
peripheral  nerves. 

Of  the  innumerable  drugs  which  produce  various  skin  lesions 
only  a  few  of  the  common  ones  used  in  a  surgical  convalescence  will 
be  named. 

An  erythematous  or  erythematopapular  eruption  is  caused  by 
acetanilid,  antipyrin,  aspirin,  benzoic  acid,  digitalis,  iodine  com- 
pounds, phenacetin,  belladonna,  sulphonal,  veronal,  potassium  chlo- 
rate, mercury,  and  morphine. 

Papular  or  pustular  eruptions  are  produced  by  the  salicylates, 
mercury,  opium,  iodine  and  bromine  compounds. 

When  drugs  which  are  known  to  cause  skin  lesions  are  given 
and  one  develops,  coming  on  suddenly  without  prodromal  symp- 
toms and  in  the  absence  of  fever,  the  drug  must  be  stopped  at 
once.  These  lesions  may  be  distinguished  from  the  acute  exanthe- 
mata by  their  symmetry  and  also  because  they  appear  both  on  the 
exposed  as  well  as  the  unprotected  surfaces  of  the  body. 

Failure  to  recognize  the  deleterious  effects  of  drugs  may  end 
in  serious  poisoning  which  can  cost  the  patient  his  life. 

Poisoning  from  local  antiseptics  is  not  rare.  An  erythematous 
eruption  is  usually  produced  by  these  agents.  The  lesion  is  usually 
bright  red  in  color  and  itches  intensely.     The  condition  is  relieved 


330  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

by  discontinuing  the  antiseptic,  and  the  skin  protected  by  some 
bland  ointment,  as  boric  or  zinc  oxide.  Here  should  be  mentioned 
the  dermatitis  following  the  application  of  iodine  tincture  which 
is  quite  frequently  seen.     Treat  by  starch  solutions. 

The  extensive  application  of  iodoform  to  an  absorbing  surface  or 
extensive  packing  with  iodoform  gauze  may  cause  poisoning.  In 
such  cases  there  is  a  general  feeling  of  malaise,  nausea,  and  the 
perception  of  odors  which  in  reality  are  not  present.  Headache 
and  vomiting  may  occur.  If  the  poisoning  is  severe  enough  there 
will  be  cerebral  excitement,  loss  of  memory  and  loss  of  appetite  and 
a  rapid  pulse.  Grave  convulsive  movements  and  maniacal  delirium 
may  alternate  with  coma,  in  which  the  patient  may  die,  the  heart 
and  respirations  ceasing  simultaneously. 

The  treatment  is  to  get  all  the  alkalies  and  water  possible  into 
the  system  by  mouth,  proctoclysis  and  hypodermoclysis.  Sodium 
bicarbonate  according  to  Sonillier  will  unite  with  the  iodine  and 
hence  this  form  of  alkali  should  be  used.  Dry-cupping  the  body 
over  the  kidney  region  and  wrapping  the  patient  in  blankets,  will 
rapidly  eliminate  that  which  is  not  excreted  by  the  kidneys.  In 
the  meantime  the  system  must  be  supported  by  alcohol  or  other 
stimulating  drugs. 

In  addition  to  the  local  effect,  extending  even  to  gangrene,  systemic 
poisoning  from  carbolic  acid  has  occurred  from  too  free  use  over 
raw  surfaces,  though  the  fatalities  arc  now  rare  indeed.  How- 
ever, many  cases  are  on  record  in  which  subacute  phenol  poisoning 
has  been  produced  by  its  absorption  from  surgical  dressings.  The 
earliest  signs  of  this  accident  are  darkened  smoky  urine,  and  slight 
nervous  unrest  or  cerebral  disturbances.  There  may  be  pain  in  the 
kidney  regions.  The  poisoning  being  severe  enough,  the  patient  be- 
comes drowsy,  pallid,  has  more  or  less  intestinal  symptoms,  and 
the  respirations  grow  labored,  stertorous,  and  coma  may  develop. 

In  the  treatment  of  this  condition  first  remove  the  cause,  wash 
the  stomach,  and  administer  large  doses  of  Epsom  salts.  Further 
treatment  consists  in  keeping  the  extremities  warm  and  the  ad- 
ministration of  respiratory  and  cardiac  stimulants.  Morphine  may 
be  required  to  relieve  the  pain.  All  the  measures  for  elimination 
should  be  employed.  At  the  same  time  as  the  skin  symptoms,  gen- 
eral ones  of  bichloride  poisoning  may  occur  after  absorption  from 
a  wound  from  a  serous  surface,  or  from  a  mucous  membrane. 
Usually  the  poisoning  is  not  of  such  severity  as  to  produce  symp- 
toms other  than  ptyalism  and  diarrhea;  but  in  the  most  severe 
forms  there  appear  cramps  in  the  limbs  and  abdomen  in  addition 


SKIN   ERUPTIONS  331 

to  the  above,  feeble  pulse,  cold  skin,  extreme  restlessness,  even 
collapse  and  death. 

Recently  Foskett12  reported  a  fatal  case  of  mercurial  poisoning 
following  a  vaginal  douche  in  which  three  7.3-gram  tablets  were  used 
in  a  cup  of  water.  The  patient  lived  twelve  days  following  the  ap- 
plication of  this  drug. 

When  poisoning  occurs,  remove  the  cause  if  possible,  and  at  once 
clear  the  stomach  by  means  of  the  tube.  Administer  at  once 
through  it  tannic  acid,  eggs,  milk  or  other  albuminous  substances. 
Such  treatment  precipitates  the  metal  and  protects  the  mucous 
membrane.  The  salivation  and  stomatitis  which  usually  follow 
such  poisoning  are  treated  by  use  of  potassium  chlorate  as  a  mouth 
wash,  particular  attention  being  given  the  teeth.  The  diarrhea 
is  controlled  with  opium;  paregoric  should  be  given  in  dram  doses 
every  hour  until  the  symptoms  cease.  Water  is  given  by  mouth 
and  rectum  followed  by  free  diaphoresis  and  diuresis. 

Erysipelas  seldom  complicates  clean  operations,  but  may  follow 
a  surgical  procedure  in  an  unclean  field,  it  may  form  an  extension 
of  the  same  or  appear  on  a  distant  portion  of  the  body.  It  usually 
occurs  in  those  patients  whose  resistance  has  been  lowered  by 
exposure,  alcohol,  old  age  or  general  debility.  The  disease  is  an 
acute,  contagious  and  very  rapidly  spreading  lymphangitis  which 
is  caused  by  the  streptococcus  pyogenes  growing  and  proliferating 
in  the  small  lymph  channels  of  the  skin  and  subcutaneous  tissue 
and  even  in  the  lymph  channels  of  the  serous  and  mucous  mem- 
branes. Though  the  disease  is  contagious,  Panton  and  Adams13 
have  definitely  shown  that  it  is  seldom  conveyed  from  one  patient 
to  another.  Of  the  various  forms  of  this  disease  the  erysipelas  sim- 
plex is  the  most  common  of  the  cutaneous  types,  which  occurs  most 
often  following  surgical  interference. 

The  symptoms  of  erysipelas  are  varied.  In  cases  of  moderate 
severity  the  condition  is  usually  preceded  for  several  hours  to  one 
or  two  days  by  prodromal  symptoms  of  constitutional  disturbance 
such  as  malaise,  chilliness,  nausea,  and  vomiting.  The  temperature 
goes  at  once  to  102°  or  more  and  after  a  decided  rigor,  and  feeling 
of  chilliness,  the  eruption  sooner  or  later  appears  about  the  wound. 
There  will  be  a  burning  and  itching  here,  and  upon  examination 
the  elevated  tender  and  reddened  lesions  with  sharply  defined  bor- 
ders will  be  seen.  The  inflammation  spreads,  the  borders  being 
acutely  inflamed  and  sinuous  in  outline.  Later,  the  center,  or  ori- 
gin of  the  infection,  the  color  and  tenderness  tend  to  disappear. 
The  temperature  remains  high,  and  the  patient  is  prostrated.    After 


332  AFTER-TREAT.MEXT   OP    SURGICAL    PATIENTS 

a  few  days  to  many  weeks  the  process  begins  to  subside,  the  swell- 
ing becomes  less  and  the  color  fades  into  a  brown  and  later  a  yel- 
lowish white.  The  blebs  which  probably  formed,  now  dry  up  and 
desquamation  takes  place.  The  constitutional  symptoms  abate  and 
the  patient  passes  out  of  danger.  In  the  old  and  in  infants  the 
mortality  is  nearly  50  per  cent.  The  general  mortality  is  not 
much  under  10  per  cent.  The  disease  is  particularly  dangerous  in 
that  gangrene  may  supervene  or  cellulitis  or  other  metastatic  in- 
fections may  occur.  Secondary  complications  like  nephritis  or 
pneumonia  often  carry  the  patient  off.  Recurrence  takes  place  in 
a  few  cases. 

The  treatment  of  this  condition  is  not  very  satisfactory.  The 
patient  should  be  isolated,  the  diet  should  be  light,  given  in  small 
quantities  every  three  or  four  hours.  Fluids  should  be  pushed 
and  every  effort  made  to  prevent  an  acidosis.  The  eliminative  treat- 
ment must  be  thorough.  The  heart  must  be  watched  closely  and 
stimulants  given  whenever  there  is  need  for  them.  Some  tonic 
which  contains  iron  and  quinine  is  useful.  For  sleeplessness  or  de- 
lirium, chloral,  bromides  or  opium  should  be  used. 

The  wound  is  kept  clean,  open,  and  a  wet  pack  of  Epsom  salts 
applied.  This  quickly  allays  the  burning  and  assists  nature  in 
draining  out  the  infectious  material.  Around  the  wound  alcohol 
and  iodine  half  and  half  may  be  painted.  In  all  cases  the  original 
wound  must  be  thoroughly  drained  and  no  agent  applied  which 
would  in  any  way  hinder  the  drainage.     Ichthyol  10-25  per  cent  has 

been  very  commonly  used  though  it  is  hard  to  say  how  much  g 1 

it  and  other  applications  do,  in  view  of  the  fact  that  the  disease 
tends  strongly  to  spontaneous  recovery.  Tim  most  modern  treat- 
ment consists  in  exposing  the  affected  area  to  the  sun's  rays  or  to 
those  of  an  incandescent  bulb,  since  both  have  an  undoubted  germici- 
dal influence. 

Bibliography 

iMcCarty:     Surg.   Gynec.   and  Obst.,   1914,  xix,   509. 

2Probyn*  and  Williams:     Administration  of  Anesthetics,  New  York,  Longmans, 
Green  &  Co. 

sBuxton:     Anesthetics.  Philadelphia,  1'.  BlaMston's  Son  &  Co. 

4Roberts:      Med.  Council.  1916,  xxi.  32. 

5Corlett:      Med.   Rec,  New   York,   1888,   \>.   172. 

sStelwagon:     Jour.  Cutan.  Dis.,  1907,  p.  117. 

^Crawford:     Therap.  (i;<z..  1898,  xiv.  660. 
-   epherd:     Jour.  Cutan.  Dis.,  July,  1909. 

9Stelwagon:      Diseas I  tin    Skin,  1914,  Philadelphia,  W.  B.  Saunders  Co. 

loEngman  and  Mook:      Jour.  Cutan.  Dis.,    L906,   p.  502. 

nMorrow:     Drug  Eruptions. 

i^Foskett.  Am.  Jour.  01>st..  1915,  hud,  6 

isPanton  and  Adams:     Lancet.  London,  Oct.  1!>09. 


CHAPTER  XLI 

HEMOPHILIA  AND  OTHER  HEMORRHAGIC  DISEASES 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

The  control  of  hemorrhage  is  naturally  of  paramount  importance 
in  operative  patients.  Usually,  very  little  trouble  is  experienced 
in  bringing  this  about,  but  occasionally  patients  are  operated  on 
account  of  the  urgency  of  surgical  condition,  without  the  surgeon 
knowing  that  they  suffer  from  some  constitutional  malady  which 
makes  hemostasis  difficult  or  even  impossible.  Of  the  diseases 
which  predispose  to  hemorrhage  apparently  through  delayed  clot- 
ting of  the  blood,  hemophilia  stands  out  in  bold  relief.  This  dis- 
ease was  first  investigated  by  Nasse  in  1820.  It  fulfills  a  law,  known 
by  this  investigator's  name  which  implies  that  the  affliction  is  lim- 
ited to  males,  being  transmitted  from  one  generation  to  another 
through  unaffected  females.  It  is  an  hereditary  malady,  clinically 
characterized  by  great  delay  in  clotting  of  the  blood,  following 
traumatic  hemorrhages.  Other  members  included  in  the  family  of 
hemorrhagic  diseases,  which  differ  widely  in  their  pathologic  con- 
ditions, but  present  hemorrhage  as  a  common  symptom,  are  the 
various  purpuras,  hemorrhagic  diseases  of  the  newborn,  jaundice, 
the  grave  anemias,  and  other  conditions  associated  with  infections 
or  chronic  ailments.  The  purpuras  are  probably  the  most  impor- 
tant class  of  diseases,  next  to  hemophilia  with  which  we  have  to 
deal.  In  purpura,  the  hemorrhages  are  spontaneous,  small  petechia 
appearing  in  the  skin  in  various  portions  of  the  body.  The  blood 
clots  within  nearly  the  normal1  time,  though  the  platelets  are  di- 
minished, which  in  hemophilia  are  normal.  Like  hemophilia,  how- 
ever, purpura  may  be  a  family  disease.  Any  doubt  arising  as  to 
the  identity  of  one  or  the  other  may  be  quickly  cleared  up  through 
subjecting  the  blood  vessel  walls  to  increased  pressure  by  means 
of  a  tourniquet.  Hemorrhages  will  occur  in  the  skin  of  patients 
suffering  with  any  hemorrhagic  diathesis;2  These  fail  to  appear  in 
hemophilia. 

After  considerable  study  of  the  hemophilic  tendency  in  families, 
Addis  concluded  that  clinically,  the  cases  fall  into  three  groups  ;3 
in  the  first  appear  those  cases  which  are  scarcely  ever  free  at  any 
time  from  some  sign  of  the  disease,  though  no  trauma  was  suffered 

333 


331  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

greater  than  those  which  come  in  everyday  events.  In  the  second 
group  trivial  accidents  alone  do  not  lead  to  prolonged  hemorrhage. 
In  the  third  group,  injuries  which  were  out  of  the  ordinary  were 
followed  by  continued  hemorrhage.  Addis  further  stated  that  the 
only  practical  difference  between  patients  of  this  group  and  ordi- 
nary individuals  was  that  hemorrhage  persisted  longer  in  the  hemo- 
philiacs. Sajous4  adds  that  the  families  are  often  large  and  the 
blondes  are  particularly  affected.  He  states  that  it  is  more  common 
in  Germany  and  among  the  Jewish  people  but  that  it  is  encoun- 
tered in  all  civilized  countries  and  especially  in  the  United  States. 
It  is  interesting  to  note  that  the  disease  may  not  only  complicate 
a  surgical  convalescence  but  also  that  it  may  be  the  cause  of  the 
operative  interference.  Schwartz3  recently  reported  sanguineous 
infiltrations  in  the  iliac  fossa,  and  especially  in  the  rectus  sheath, 
which  led  to  appendiceal  symptoms  and  subsequent  operation. 

Hemorrhages  may  occur  in  the  joints,  producing  swelling,  pain, 
and  fever,  following  some  slight  exertion.  Hemotomata  may  appear 
in  various  regions  of  the  body  due  to  trauma  which  may  have  been 
so  slight  that  the  patient  failed  to  recall  it.  Such  tumors  arising 
within  the  psoas  muscle  or  other  obscure  regions,  may  simulate 
other  conditions  which  are  urgently  operative,  the  true  nature  of 
the  disease  not  being  manifest  until  the  blood  tumor  is  discovered. 

The  hemorrhagic  diseases  have  not  as  yet  been  satisfactorily 
classified  since  the  causes  of  the  conditions  are  not  known,  and 
even  in  hemophilia,  which  disease  has  been  more  thoroughly  studied 
than  the  rest,  Morawitz  and  Lossen  are  contented  to  say  that  "we 
have  to  deal  with  an  inherited  chemical  degeneration  of  the  proto- 
plasm of  the  formed  elements  of  the  blood  and  perhaps  of  the 
whole  organism. '  'G 

The  coagulation  of  the  normal  blood  is  explained  by  many  dif- 
ferent theories,  probably  the  most  dependable  one  being  that  of 
Morawitz,  and  one  which  is  supported  by  Wright,  that  in  normal 
individuals,  the  blood  clot  is  formed  in  the  following  manner: 
thrombokinase  in  the  presence  of  calcium  salts  converts  throm- 
bogen  into  thrombin  and  this  converts  fribrinogen  into  fibrin, 
which  is  the  essential  feature  of  the  blood  clot.  The  enzyme  throm- 
bokinase is  not  present  in  the  circulating  blood  but  is  formed 
through  the  breaking  up  of  the  leucocytes  during  hemorrhage  and 
from  the  injured  cells  in  the  wound.  Fibrinogen,  thrombogen  and 
calcium  are  present  in  the  circulating  blood.  The  existence  of  the 
fibrin  ferment,  fibrinogen  in  the  blood  has  been  definitely  demon- 
strated.   It  is  a  protein  body  which  forms  .22  per  cent  to  .4  per  cent 


HEMOPHILIA   AND   OTHER    HEMORRHAGIC    DISEASES  335 

of  the  plasma.7  The  thrombogen  has  never  been  isolated  though 
it  is  believed  to  occur  in  the  circulating  blood.  The  thrombin  ap- 
pears only  after  the  blood  is  shed,  hence  it  seems  reasonable  to 
suppose  that  its  constituent  elements  must  have  existed  in  the  cir- 
culating blood,  and  are  therefore  termed  thrombogen.  Thrombin 
has  been  thoroughly  studied  by  Howell.  The  presence  of  calcium 
in  this  medium  has  long  been  known.  The  existence,  however,  of 
fibrinogen,  thrombin,  fibrin,  and  calcium  is  definitely  proved. 
Thrombokinase  and  thrombogen  occur  only  in  theory.  Just  how 
thrombin  is  formed  is  still  a  matter  of  controversy ;  even  the  mode 
of  action  of  thrombin  on  fibrinogen  is  not  understood.  Whether 
it  is  a  ferment  action,  a  chemical  or  a  physicochemical  action  is  still 
a  question.8 

It  naturally  follows  that  an  abnormal  clotting  of  the  blood  could 
hardly  be  explained  if  the  normal  mechanism  is  not  understood. 
However,  many  theories  have  been  advanced  to  explain  the 
phenomenon.  Morawitz  and  Lossen  say  the  delay  in  the  coagulation 
time  is  due  principally  to  insufficient  formations  of  the  fibrin  fer- 
ment factors,  especially  the  thrombokinase.  The  same  view  was 
held  three  years  before  by  Sahli9  who  stated  that  he  could  not  tell 
which  of  the  cellular  elements  of  the  blood  was  lacking  but  he  con- 
sidered the  thrombokinase  was  not  available  in  normal  amounts. 
Addis10  reported  in  1910,  12  cases  of  hemophilia  in  which  the  pathol- 
ogy had  been  studied.  The  coagulation  time  in  all  was  from  one 
to  two  hours,  and  the  only  constant  factor  present  so  far  as  pa- 
thology goes,  was  the  delay  in  the  coagulation  of  the  blood.  He 
thinks  this  is  due  to  the  slow  action  of  the  thrombogen  in  chang- 
ing into  thrombin  even  in  the  presence  of  normal  amounts  of  throm- 
bokinase and  calcium  salts.  In  his  opinion,  hemophilia  is  probably 
due  either  to  an  absence  of,  or  to  too  small  amounts  of,  or  to  some 
change  in  the  thrombogen.  Howell  also  considers  the  thrombogen 
at  fault.  Wright11  considered  delay  in  coagulation  time  was  due 
to  lack  of  calcium.  Kahn12  studying  two  hemophiliacs,  one  an 
hereditary  "bleeder"  and  one  who  had  no  such  history  but  was 
considered  a  sporadic  type  of  this  disease,  by  metabolism  studies 
showed  the  calcium  content  of  the  blood  normal  in  the  typical 
hemophiliac  while  in  the  atypical  case,  it  was  decreased.  Adminis- 
tration of  calcium  diminished  the  coagulation  time  in  the  atypical, 
while  it  even  increased  it  in  the  true  hemophiliac.  There  was 
no  derangement  in  metabolism  as  measured  by  the  intake  and  out- 
put of  nitrogen,  sulphur,  and  calcium  in  the  true  hemophiliac.  He 
concludes  that  "there  are  certain  bleeders  in  whom  the  disturbing 


336  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

factor  seems  to  be  a  lack  of  calcium  content  of  the  blood  and  an 
inability  on  the  part  of  the  organisms  to  assimilate  properly,  the 
lime  from  the  food." 

The  prognosis  is  particularly  grave  during  the  first  year  as  Et- 
linger13  has  shown.  The  disease  frequently  disappears  at  puberty, 
in  mild  cases.  Boys  are  worse  risks  than  girls.14  With  sufficient 
care,  patients  live  until  middle  life,  the  longer  the  patient  lives,  the 
greater  the  chance  of  out-living  the  tendency.  The  prognosis  in 
each  individual  case  should  be  based  on  the  patient's  history  and 
that  of  his  family.13 

Treatment. — The  treatment  of  such  conditions  naturally  is  em- 
pirical and  will  remain  so  until  more  definite  causes  have  been 
found  for  these  diseases.  In  the  meantime,  we  consider  the  first 
step  toward  the  successful  handling  of  these  unfortunate  patients 
is  to  be  on  the  lookout  for  their  appearance,  and  if  possible,  diag- 
nose the  condition. 

All  careful  surgeons,  before  any  operative  procedure,  examine 
their  cases  so  far  as  possible  for  such  disorders  of  the  blood  in 
order  to  escape  the  misfortune  which  comes  as  consequences  of 
operating  upon  such  patients.  Even  after  most  thorough  histories 
and  physical  examinations,  patients  occasionally  first  present  this 
complication  during  the  operation.  Only  the  most  urgent  opera- 
tions are  performed  on  known  hemophiliacs.  However,  the  clotting 
time  being  normal,  almost  any  operation  is  undertaken  regard- 
less of  other  preoperative  findings.  Hess  says  this  is  a  mistake. 
He  thinks  that  too  great  stress  is  laid  upon  the  clotting  time,  espe- 
cially of  blood  taken  in  the  usual  way,  i.e.,  from  a  cut  in  the  skin. 
He  considers  it  far  more  important  to  get  the  clotting  time  of 
blood  taken  directly  from  the  blood  vessels  themselves.  In  addi- 
tion, puncture  wounds  should  be  noted  for  absence  or  presence 
of  hemorrhage.  In  patients  whose  history  points  to  this  condition, 
we  heartily  recommend  Hess'  advice,  otherwise  we  prefer  to  ex- 
amine the  blood  from  a  cutaneous  puncture,  several  separated 
drops  having  been  placed  upon  a  clean  glass  slide.  At  the  expira- 
tion of  one  minute,  a  pinpoint  placed  in  one  drop  of  blood  will  show 
a  fine  thread  of  fibrin  if  the  blood  coagulates  so  soon.  If  not,  use 
another  drop  and  repeat  t lie  maneuver  until  a  thread  appears  and 
note  the  time.  The  fibrin  should  appear  within  three  to  five 
minutes. 

According  to  Morris,15  among  the  best  methods  of  determining 
the  clotting  time  is  one  which  utilizes  the  apparatus  of  Brodie  and 
li'ns^ell  as  improved  by  Boggs.16     Morris  says  that  results  nearly 


HEMOPHILIA   AND    OTHER    HEMORRHAGIC    DISEASES  337 

as  uniform  have  been  obtained  by  Hinman  and  Sladen,17  who  use 
a  modification  of  Milian's  idea.  Since  the  apparatus  required  in 
the  latter  method  consists  of  a  plain  glass  slide  and  a  millimeter 
rule  only,  we  have  used  this  method  in  cases  requiring  a  more  ac- 
curate determination  of  the  blood  clotting  time.  The  method  con- 
sists in  aseptically  obtaining  blood  from  a  blood  vessel  as  sug- 
gested by  Hess.  Several  small  drops  are  placed  upon  a  clean  glass 
slide,  by  touching  the  undersurface  of  the  slide  to  the  hanging  drop. 
The  slide  is  turned  quickly  to  prevent  the  drops  from  flowing  and 
then  placed  over  the  millimeter  scale.  All  the  drops  are  wiped  away 
except  those  measuring  4  and  5  mm.  in  diameter.  The  slide  is  held 
vertically  and  the  profile  of  the  drops  watched.  They  first  sag 
as  would  a  tear,  but  as  soon  as  coagulation  takes  place,  uniform 
convexity  appears.15  It  is  also  worthy  of  note  that  through  trans- 
mitted light,  the  dependent  portion  of  the  drops  appears  the  denser. 
When  coagulation  has  occurred,  the  center  of  the  drop  assumes 
this  density.  The  presence  of  a  clot  is  confirmed  by  use  of  the 
pinpoint  or  by  transferring  the  whole  drop  to  a  piece  of  cloth.  Ac- 
cording to  Morris,  5-millimeter  drops  alone  should  be  used  in  de- 
layed clotting  since  the  error  due  to  evaporation  is  thereby 
markedly  decreased.  The  mean  coagulation  time  of  all  the  4  and 
5  mm.  drops  of  unknown  blood,  is  taken  for  the  result.  The  blood 
must  clot  below  8  min.  to  be  considered  normal  with  this  method; 
usually  normal  blood  does  not  clot  in  less  than  five  minutes. 

In  Addis'  12  cases  of  hemophilia,  the  clotting  time  was  from  15 
to  85  minutes.  In  Morawitz  and  Lossen's  case,  the  blood  took  110 
minutes  to  clot  completely.  Blood  taken  from  the  veins  of  such 
patients,  2  c.c.  or  more  and  placed  at  a  temperature  of  20°  to  22° 
C,  will  not  clot  for  hours. 

The  hemostatic  measures  which  have  been  employed  in  the  past 
are  numerous.  Excluding  the  direct  measures,  such  as  ligating  the 
bleeding  vessels,  tamponading,  etc.,  and  considering  drugs  alone, 
the  lactate  of  calcium  is  probably  of  most  value,  since  in  some  of 
the  instances  the  hemorrhage  was  associated  with  a  lack  of  this 
mineral  in  the  blood.  These  cases  alone,  however,  can  be  benefited 
by  such  medication.  Calcium  will  even  increase  the  delay  in  the 
clotting  time  in  some  cases  and  its  use  should  not  be  continued 
over  too  long  a  time. 

Thyroid  gland,  3  to  5  grains,  three  times  a  day  has  been  suc- 
cessfully employed  by  Delace,ls  Rugh,19  and  others,  both  as  a  pre- 
ventive and  as  curative  means,  particularly  in  hemophilia.  Re- 
cently Witte's  peptone  has  been  highly  praised  by  various  Euro- 


338  AFTER-TREATMENT   OF   SURGICAL   PATIENTS 

pean  writers.  Nolf  and  Herry20  advise  the  injection  of  10  c.c.  of  a 
5  per  cent  solution  in  0.5  per  cent  sodium  chloride.  The  mixture 
is  made  by  adding  5  grams  of  peptone,  0.5  grams  of  sodium  chloride 
to  100  c.c.  distilled  water.  Its  properties  are  not  altered  by  ster- 
ilization and  it  is  given  snbcntaneoiisly.  Considerable  pain  is  noted 
at  times  at  the  site  of  the  injection  with  elevation  of  temperature. 
It  is  rarely  necessary  to  repeat  the  close  more  than  once,  usually 
after  a  day  or  more  has  elapsed.  Nobecourt  and  Tixier21  who 
probably  have  had  the  most  experience  with  this  treatment,  give 
four  to  six  subcutaneous  injections  of  3  to  5  c.c.  of  the  solution 
at  each  injection  two  to  three  days  apart.  This  can  be  given  before 
operation  or  following  it,  but  in  either  event,  four  to  six  weeks 
should  elapse  before  a  second  series  is  given.  Following  this  rule, 
no  untoward  symptoms  developed  after  its  use.  Intolerance  to  pep- 
tone lias  been  reported,  however,  but  it  followed  the  administra- 
tion over  too  long  a  period  of  time.22 

The  use  of  fresh  human  serum  has  long  been  held  to  be  the  best 
agent  for  controlling  this  malady.  It  is  asserted  by  some  that 
Witte's  peptone  is  better  than  serum  but  until  it  is  proved,  fresh 
human  serum  will  remain  the  most  efficient  means  we  have  to  com- 
bat the  dangers  which  follow  operations  upon  patients  with  hemo- 
philic tendencies.  The  investigations  of  Weil  have  resulted  in  this 
form  of  treatment.  However,  almost  three  years  before  Weil 
published  his  work,  Bienwald,23  Felz  and  Pigot,24  Fry25  and  others 
had  used  fresh  serum  successfully  in  almost  hopeless  cases  of 
hemorrhage  due  either  to  hemophilia  or  other  of  the  hemorrhagic 
diseases.  Weil's26  observations  were  based  upon  the  treatment  of 
eleven  cases  of  hemophilia  in  some  of  which  the  preventive  use 
was  made  of  the  serum.  He  also  used  it  in  cases  with  marked  pri- 
mary and  secondary  purpura  and  in  other  hemorrhagic  diseases, 
and  concluded  even  at  that  early  date  (1906)  that  "fresh  serum 
is  an  effective  remedy  for  the  arresting  of  hemorrhage  in  all  dys- 
crasic  states,  in  fact  more  effective  than  any  other,  including  cal- 
cium salts."  Weil's  work  was  quickly  confirmed  by  that  of  Elica- 
garay27  and  soon  its  use  became  general.  Fresh  sera  from  the  rab- 
bit, cow,  ox,  goat,  and  horse,  were  used  and  found  effective. 
Baum28  could  not  agree  with  all  the  findings  of  Weil  but  stated  that 
he  considered  serum  Avas  indicated  in  all  hemorrhagic  conditions 
and  would  expect  good  results  from  it,  except  possibly  in  true 
hemophilia. 

Following  the  injections  of  fresh  serum,  other  stock  sera  were 
used  and  in  some  cases  with  good  results.     Diphtheria  antitoxin, 2S 


HEMOPHILIA   AND    OTHER    HEMORRHAGIC    DISEASES  339 

tetanus  antitoxin,29  antistreptococcic30  serum  and.  other  sera  of 
various  kinds  were  tried,  but  none  with  universal  success.  After 
extensive  trial  of  sera,  it  was  found  that  the  serum  from  the  ox, 
goat,  and  dog  were  particularly  apt  to  produce  anaphylaxis  and 
it  became  so  universally  known  that  Trembur31  in  1910,  stated  that 
the  kind  of  serum  should  be  changed  at  the  slightest  sign  of  such 
a  condition.  During  the  same  year,  Broca32  considered  the  use  of 
animal  sera  permissible  for  the  arrest  of  hemorrhage  in  cases  of 
true  hemophilia  only.  One  year  later,  Moss  and  Gelien  used  large 
intravenous  doses  of  defibrinated  blood  which  they  hoped  would 
not  only  furnish  the  element  necessary  to  cause  the  coagulation  of 
the  blood,  but  also  relieve  the  marked  anemia. 

Duke33  considered  the  cause  of  the  uncontrollable  bleeding  due  to 
a  deficiency  or  to  an  absence  of  the  platelets  in  the  blood  in  some 
of  the  hemorrhagic  diseases  at  least.  He  therefore  advised  blood 
transfusion  as  the  most  efficient  method  of  overcoming  the  condi- 
tion. There  can  be  no  cpiestion  of  this  being  the  ideal  method  easy 
of  accomplishment.  Satisfactory  results  have  been  reported  by 
Goodman,34  Murphy,35  and  others,  in  cases  which  no  doubt  would 
have  terminated  fatally  if  this  procedure  had  not  been  resorted  to. 

Welch36  in  1910  was  so  successful  in  treating  hemophilic  babies 
with  fresh  human  serum  that  others  have  again  revived  its  use. 
Among  those  who  have  employed  this  method  in  operative  patients 
may  be  mentioned  Meyer,37  who  used  it  as  a  preventive  measure  in 
cases  of  chronic  jaundice  and  as  a  hemostatic  in  postoperative 
hemorrhages  in  such  patients.  Tilton3S  also  used  the  fresh  human 
serum  successfully  as  a  preventive  treatment  in  such  cases. 

The  amount  of  fresh  human  serum  to  be  given  depends  on  the 
individual  case.  In  hemophilic  babies,  Welch  gave  10  c.c.  of  the 
serum  subcutaneously,  repeated  two  and  three  times  a  day,  but 
would  give  this  dose  every  two  hours  if  necessary.  He  states  that 
the  error  most  commonly  made  is  the  giving  of  too  small  doses. 
Meyer  gave  30  c.c.  subcutaneously  three  times  a  day  for  the  first 
day,  30  c.c.  each  day  for  three  days  more  just  before  the  operation, 
and  30  c.c.  during  the  operation.  If  there  is  a  tendency  to  bleeding 
during  the  convalescence,  the  injections  are  continued.  Usually 
100  c.c.  are  given  during  the  first  day  hemorrhage  is  noticed  and 
the  dosage  gradually  diminished  until  there  is  no  further  oozing. 
If  the  serum  is  given  intravenously,  the  dosage  is  not  so  great; 
Weil  would  cut  the  amount  in  half  as  compared  to  the  subcuta- 
neous injection. 

Welch  positively  states  that  serum  sickness  does  not  arise  from 


340 


AFTER-TREATMEXT   OF    SURGICAL   PATIENTS 


the  use  of  this  serum  but  on  the  other  hand  "it  is  a  perfect  food 
already  digested  and  ready  to  be  taken  up  and  utilized  by  the  tis- 
sues and  cells  of  the  body."  The  subcutaneous  injections  do  not 
cause  pain  and  are  most  readily  absorbed. 

In  securing  the  serum  for  injection,  the  donor  must  he  healthy. 


Fig.   49. — Apparatus  used  by  Welch   for  collecting  blood  serum. 

It  is  preferable  to  have  a  Wassermanu  done  if  possible.  The  col- 
lection may  be  easily  accomplished  by  means  of  an  apparatus  which 
Welch  first  described  in  1!)1<),  and  which  is  shown  in  Fig.  40.  The 
needle  of  No.  19  caliber,  is  plunged  into  the  median   basilic  vein 


HEMOPHILIA   AND    OTHER    HEMORRHAGIC    DISEASES  341 

and  the  blood  collected  in  the  flask.  "When  the  desired  amount  is 
obtained,  the  flask  is  placed  in  a  slanting  position  in  a  basin  where 
it  remains  four  to  six  hours.  After  this  time,  the  serum  will  have 
separated  and  will  be  ready  for  use. 

Locally,  the  same  agents  may  be  applied  to  the  oozing  surfaces 
as  have  been  discussed  for  subcutaneous  or  intravenous  use.  If 
any  of  the  stock  sera  are  at  hand,  they  may  first  be  applied.  It 
is  not  advisable  to  depend  on  any  chemical,  since  none  have  proved 
trustworthy  and  the  most  efficient  we  have  (adrenalin)  may  even 
cause  a  worse  hemorrhage  after  the  temporary  effects  wear  off. 
Probably  the  quickest  means  at  the  surgeon's  disposal,  is  to  place 
fresh  human  blood  on  the  surface.  Sayer39  recently  stopped  bleed- 
ing by  applying  a  few  drops  of  his  own  blood  and  other  instances 
are  reported  in  which  relatives  gave  blood  which  was  utilized  in 
this  way.23  The  thrombokinase,  which  seems  necessary  for  coagula- 
tion may  be  supplied  by  kneading  the  tissues  around  the  wound 
or  by  placing  fresh  tissue  juices  into  it  if  fresh  serum  can  not  be 
had  readily.40 

As  a  last  resort,  while  fresh  human  serum  is  being  secured  for  in- 
ternal medication,  the  bleeding  surface  may  be  seared  with  the 
cautery  which  is  not  at  a  red  heat.  Hahn  reported  two  cases  of 
hemorrhage  from  the  gum  and  in  which  this  most  radical  measure 
saved  life. 

Constitutional  treatment  should  be  continued  several  days  after 
the  local  bleeding  has  stopped  and  general  measures  instituted 
which  will  help  the  patient  regain  the  lost  hemoglobin. 

Bibliography 

iHess:     Bull.  Johns  Hopkins  Hosp.,  1915,  xxvi,  264. 

sFrugoni  and  Giughi:      Semaine  mecl.,  January,  1911. 

s Addis:     Quart.  Jour.  Med.,  October,  1910. 

*Sajous:     Analytic  Cyclopedia  Practical  Med.,  1916,  v,  415. 

sSchwartz:     Paris  Med.,  October,  1.912. 

eMorawitz  and  Lossen:     Deutsch.  Arch.  f.  klin.  Med.,  1908,  xciv,  110. 

7Moss  and  Gelien:     Bull.  Johns  Hopkins  Hosp.,  1911,  xxii,  273. 

sHowell:     Am.  Jour.   Physiol.,  1910,  xxvi,  453. 

9Sahli:     Ztschr.  f.  klin  Med.,  lvi,  1905. 
"Addis:     Brit.  Med.  Jour.,  Nov.  5,  1910,  p.  1422. 
ii Wright :     Quoted  by  Kahn.12 
isKahn:     Am.  Jour.  Dis.  Child.,  1916,  ii,  104. 
isEtlinger:     Jahrb.  f.  Kinderh.,  1901,  liv,  24. 
lOsler-McCrae :     Modern  Medicine,  1914,  iv,   727. 
isMorris:      Clinical  Laboratory  Methods,   New  York,  1913,     D.  Appleton  &  Co., 

p.  261. 
"Internal;.  Clinics,  1908,  i,  31. 

I'Hinman  and  Sladen :     Bull.  Johns  Hopkins  Hosp.,  1907,  xviii,  207. 
isDelace:     Jour,  de  med.  de  Paris,  January,  1898. 
isRugh:     Ann.  Surg.,  May,  1907. 


342  AFTER-TREATMENT   OP   SURGICAL   PATIENTS 

soN/olf  and  Horry:     Rev.  de  med.,  February,  1910. 

2iNobecourt  and'  Tixier:      Bull,  med.,   Paris,  October,   1910. 

22Lereboullet  and  Vaucher:     Bull.  Soc.  de  Pediat,  de  Paris,  1914,  iii,  132. 

23Bien\vald:     Deutsch.  med.  Wchnschr.,  1897,  No.  83. 

24Felz  and  Pigot:     Gaz.  Hebdomadoire,  1897,  No.  83. 

25Fry:      Med.  Rec,  New  York,  1898. 

zeWeil:      Lancet,  London,   March   7,   1907;    also   Med.   Rec,   New  York,  August, 

1908,  p.  322. 
27Elicagary:     These  de  Paris,  1907. 

2sBaum:     Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1909,  xx,  1. 
29Toussaint:     Brit.  Med.  Jour.,  Apr.  6,  1907. 
soLommel:     Centralbl.  f.  Inn.  Med.,   1908.  xxix,  (377. 
siTrembur:      Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1910,  xxii,  1. 
32Broca:     Lancet,  London,  1910,  ii,  203. 
33Duke:     Jour.  Am.  Med.  Assn.,  1910,  Iv,  1185. 
34Goodman:      Ann.    Surg.,    1910,  lii,    457. 
35Murphy:     Boston  Med.  and  Surg.  Jour.,  1908,  clix,  865. 
36\Velcli:     Am.  Jour.  Med.  Sc,  1910,  cxxxix,  12. 
37Meyer:      Surg.,  Gynec.  and  Obst.,   1911,  xiii,   1"_. 
38Tilton:     Med.  Rec.,  New  York,  September,  1910. 
39Sayer :     Jour.  Am.  Med.  Assn.,  Jan.  13,  1912. 
40Gressot :     Ztschr.  f.  klin.  Med.,  1912,  lxxvi,  3. 
ullahn:     Munich  med.  Wchnschr.,  May,  1913. 


CHAPTER  XLII 

ARTIFICIAL  RESPIRATION 
By  Willard  Bartlett  and  Adolpli  Rumreich 

We  will  here  consider  artificial  respiration  as  a  resuscitatory 
measure.  The  historical  development  of  the  procedure  will  not 
be  entered  into  here. 

Resuscitation,  which  consists  almost  entirely  of  methods  of  arti- 
ficial respiration,  becomes  called  for  in  cases  of  suspended  anima- 
tion from  any  of  a  number  of  causes,  such  as  excess  of  chloroform 
or  ether  anesthesia,  morphia  narcosis,  acute  cocaine  poisoning, 
drowning,  electric  shock,  gas  poisoning  (carbon  monoxide),  suf- 
focation, increased  intracranial  pressure  (e.g.r  with  hemorrhage, 
meningitis,  etc.)  Respiratory  embarrassment  under  general  anes- 
thesia will  be  chiefly  kept  in  mind  though  most  of  the  same  general 
methods  are  applicable  in  respiratory  failure  due  to  any  of  the 
above  causes.  Artificial  respiration  in  its  application  to  thoracic 
surgery  will  not  be  considered  here. 

To  be  effective,  artificial  respiration,  no  matter  by  what  method 
it  is  effected,  must  be  instituted  early,  immediately  after  respira- 
tion has  failed,  if  possible.  It  is  also  indicated,  of  course,  whenever 
signs  of  impending  cessation  of  respiration  develop  on  the  operat- 
ing table.  In  ail  eases  of  suspended  animation,  the  probability  of 
restoration  decreases,  as  someone  has  put  it,  in  an  arithmetical 
progression  from  the  moment  when  spontaneous  respiration  ceases. 
The  lungs  and  heart  possess  a  considerable  degree  of  irritability,1 
and  the  respiratory  centers  have  a  stronger  resistance  than  other 
parts  of  the  nervous  system,2  but  the  weak  point  is  the  brain.  After 
ten  to  fifteen  minutes  of  complete  circulatory  failure,  brain  func- 
tions are  not  recovered.  In  chloroformed  dogs  the  time  limit  is 
even  less.3  In  man,  recovery  is.  very  uncertain  beyond  a  ten  min- 
ute interval.  However,  as  the  heart  may  beat  for  some  time  after 
respiration  has  ceased,  so  faintly  as  not  to  be  detected,  efforts  at 
resuscitation  should  be  persevered  in. 

Manual  Methods  of  Artificial  Respiration 

Howard's  Method. — In  this,  known  also  as  the  "direct  method," 
the  principle  is  active  expiration  by  compression,  and  passive  in- 

343 


344  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

spiration  by  the  recoil  of  the  thoracic  wall.  The  patient  is  placed 
in  the  dorsal  position,  and  a  support,  such  as  a  pillow,  is  placed 
under  the  hack,  which  produces  hyperextension  of  the  spine  and 
renders  the  subcostal  margin  prominent.  The  operator  places  his 
hands  over  the  prominent  subcostal  margins,  the  palms  being  be- 
low the  margins,  the  fingers  in  the  furrows  between  the  ribs,  and 
exerts  pressure.  The  diaphragmatic  ribs  are  thus  depressed,  the 
abdominal  contents  push  the  diaphragm  upward,  and  the  spine  is 
partially  straightened.  The  recoil  after  release  of  the  pressure 
effects  inspiration.  With  this  method  an  abdominal  type  of  respira- 
tion is  produced.  Advocates  of  it  claim  as  an  advantage  that  the 
blood  is  forced  through  the  pulmonary  circulation. 

Silvester's  Method. — This  was  termed  by  the  originator  the 
"physiologic  method."  The  patient  is  in  the  supine  position.  The 
operator  stands  at  the  patient's  head,  and  seizing  the  bent  arms 
above  the  elbows,  lifts  them  towards  the  patient's  chin,  thus  ren- 
dering the  pectoral  muscles  taut.  This  effect  is  increased  by  evert- 
ing or  laterally  rotating  the  arms  as  they  are  lifted.  The  arms  are 
then  carried  back  towards  the  patient's  ears;  the  humerus  and 
shoulder  are  thus  used  as  levers  and  the  anterior  wall  of  the  chest 
is  raised  upward  and  forward.  The1  arms  are  held  thus  extended 
for  a  second  or  two;  expiration  is  then  produced  by  pressing  the 
patient's  arms  firmly  against  the  lateral  Avails  of  the  chest.  The 
rate  should  be  about  fifteen  times  per  minute. 

Brosch's  Modification  of  Silvester's  Method. — 1.  After  the  arms 
have  been  extended  as  recommended  by  Silvester  (Fig.  50),  the 
movement  is  continued  forcibly  until  the  arms  actually  touch  the 
table  on  which  the  patient  is  placed.  This  causes  the  body  to  arch 
upward  so  that  it  rcsis  mi  the  tabic  only  at  the  shoulders  and  heels; 
the  spine  is  hyperextended.  Withdrawal  of  the  force  lets  the  body 
recoil  on  the  table,  and  collapse  of  the  chest  commences.  2.  In  the 
respiratory  movement  the  patient's  arms  are  pressed  directly  over 
the  sternum  and  the  costal  cartilages  (Fig.  51),  which  are  forced 
inwards.  By  this  method  a  maximum  active  inspiration  and  a 
maximum  active  expiration  ace  secured,  and  a  respiratory  exchange 
greater  than  by  any  other  method,  as  measured  in  cubic  centime- 
ters per  minute,  is  obtained.  Some  have  even  recommended  addi- 
tional pressure  on  the  abdomen4  or  the  addition  of  Howard's 
method"1  to  augment  the  effect.  The  danger  of  acapnia  by  over- 
ventilation  (Haldane  and  Henderson)  with  such  a  procedure  has 
been  pointed  out,  while  the  hyperpnea  produced  may  even  lend  to 
death  through  shock.''     The  expiratory  maneuver  of  Brosch's  modi- 


ARTIFICIAL    RESPIRATION 


345 


flcation  of  the  original  Silvester  method  is  generally  acknowledged 
as  a  valuable  feature  and  is  now  widely  used. 
Silvester-Howard  Method. — The   operator  performs  the   maneu- 


Fig.    50. — First  act  in  the   Sylvester  method. 


Fig.   51. — Second  act  in  the   Sylvester  method. 


vers  of  the  Silvester  method,  while  an  assistant  synchronously 
goes  through  Howard's  maneuver — thus  effecting  greater  ventila- 
tion. 


346  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

In  any  supine  posture  method  the  position  allows  the  patient's 
tongue  to  fall  hack  against  the  posterior  pharyngeal  wall,  and  the 
epiglottis  to  close  the  larynx.  The  tongue  should  therefore  be  se- 
cured. If  the  patient  is  in  a  supine  posture,  the  head  should  hang 
down  over  the  edge  of  the  table,  or  the  shoulders  may  be  elevated 
so  as  to  lower  the  head ;  the  head  and  neck  are  to  be  extended  as 
much  as  possible.  Howard  showed  that  by  this  procedure  the  epi- 
glottis is  completely  removed  from  the  glottis,  and  a  free  passage 
of  air  is  allowed.  Martin  and  Hare,  however,  showed  that  this  po- 
sition causes  the  soft  palate  to  strap  itself  over  the  root  of  the 
tongue  so  as  to  cut  off  the  entrance  of  air  through  the  mouth. 
They  proved  that  if  the  head  be  extended  and  at  the  same  time 
projected  forward,  the  above  condition  is  obviated,  and  at  the  same 
time  the  epiglottis  is  well  raised  from  the  glottis,  thus  permitting 
free  breathing  through  both  mouth  and  nose.8'  9 

Schafer's  Prone-Pressure  Method. — By  this  method  the  lower 
part  of  the  thorax  is  compressed,  and  in  addition  the  diaphragm 
forced  upward  by  the  abdominal  viscera.  The  patient  is  laid  in 
the  prone  position,  the  face  turned  slightly  to  one  side,  so  as  to 
leave  the  nose  and  mouth  free  for  breathing.  An  assistant  draws 
the  tongue  forward.  The  operator  kneels  beside  or  straddles  the 
patient's  thighs,  facing  his  head,  and  applies  his  hands  to  the  back, 
one  on  each  side  of  the  spinal  column,  the  palms  on  the  muscles 
at  the  small  of  the  back,  thumbs  nearly  touching  each  other,  and 
fingers  spread  over  the  lower  ribs.  Keeping  his  arms  straight,  the 
operator  with  a  forward  swing  throws  the  weight  of  his  body  slowly 
upon  the  patient,  thus  causing  contraction.  This  movement  takes 
two  to  three  seconds.  He  then  raises  his  body  and  relaxes  pres- 
sure, allowing  the  thorax  to  expand  by  recoil.  After  two  seconds 
the  movement  is  repeated.  The  complete  movement  thus  occupies 
four  or  five  seconds,  giving  a  rate  of  12  to  15  times  per  minute. 
The  method  is  rendered  more  effective  if  the  arms  are  extended 
forward  as  straight  as  possible.7 

There  is  considerable  controversy  over  the  merits  and  faults  of 
the  various  manual  methods.  All  have  been  accused  by  the  op- 
ponents of  causing  rupturing  of  the  congested  liver  or  fracturing 
the  ribs,  especially  in  old  persons.  These  accidents  are  very  rare  and 
are  manifestly  due  to  improper  technic. 

The  prone  posture  permits  mucus  and  saliva,  which  are  secreted 
excessively  in  general  anesthesia,  to  flow  out  of  the  mouth.  Of  the 
supine  posture  methods  the  Silvester  method  with  the  Brosch  ex- 
piratory modification  is  most  widely  used.     The  choice  of  position 


ARTIFICIAL    RESPIRATION  347 

and  method  is  evidently  determined  by  the  conditions  in  each  case 
where  employed  during  a  surgical  operation. 

Artificial  Respiration  with  Apparatus 

Pulmotor. — This  is  an  ingenious  mechanical  device,  consisting  of 
a  tank  of  compressed  oxygen,  connected  through  a  reducing  valve 
with  an  injector  to  draw  in  air,  a  hose  delivering  the  air-oxygen  mix- 
ture to  a  close-fitting  face  mask,  and  an  automatic  mechanism  to 
regulate  expiration  and  inspiration.  Serious  faults  were  found 
by  the  Commission  on  Resuscitation;7  among  them,  that  any  ob- 
struction to  the  flow  of  air  will  cause  such  a  rapid  succession  of 
suction  and  injection  as  to  make  the  apparatus  inefficient  and  that 
the  automatic  reversal  mechanism  readily  gets  out  of  order.7  The 
''Pulmotor  Model  B"  is  a  newer  apparatus,  in  which  the  automatic 
feature  is  replaced  by  a  hand  control.  Compressed  air  or  oxygen 
or  an  electric  air  blower  may  furnish  the  motive  power.  This  form 
of  instrument  is  preferable  to  the  automatic  type.  The  latter  in 
fact  should  be  condemned.  As  to  the  actual  amount  of  oxygen 
delivered  in  the  air-oxygen  mixture,  Haidane  and  Henderson  found 
it  to  be  only  26.75  per  cent,  which  is  not  much  enrichment,  consider- 
ing that  pure  air  contains  21  per  cent  oxygen. 

The  Dr.  Brat  apparatus  is  similar  to  the  pulmotor,  except  that  it 
feeds  pure  oxygen,  and  produces  greater  pressure  and  suction.  It 
is  hand  regulated. 

Lungmotor. — This  device  consists  of  two  pumps,  connected  by  a 
hose  to  the  face  mask,  and  so  arranged  that  the  down-stroke  in- 
jects air,  while  the  up-stroke  produces  suction.  An  oxygen  tank 
may  be  connected  up  and  the  injected  air  enriched  with  oxygen  to 
the  desired  degree. 

Several  other  devices,  all  similar  to  those  above  described,  and 
made  on  the  same  principle,  are  on  the  market.  Objection  has  been 
offered  to  the  suction  feature  of  these  devices  by  the  Commission 
on  Resuscitation7  and  others  on  the  ground  that  it  causes  collapse 
of  many  of  the  alveoli,  which  then  stick  together  and  are  not  ef- 
fective, also  that  it  causes  collapse  of  some  of  the  bronchioles, 
which  traps  a  certain  amount  of  air  in  a  dead  space,  the  movement 
of  which  simulates  respiratory  movements  with  an  actually  les- 
sened gaseous  exchange. 

Meltzer's  Pharyngeal  Insufflation  Apparatus. — 10>  "  With  this  ap- 
paratus the  necessary  inspiratory  pressure  is  obtained  by  means  of 
a  foot  bellows,  or  from  an  oxygen  tank  or  other  source  of  constant 


348  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

pressure.  The  air  or  oxygen  is  delivered  by  a  hose  to  the  pharyn- 
geal tube,  which  is  so  constructed  as  to  close  the  entrance  to  the 
nasopharynx  and  thus  prevent  escape  of  air  through  the  nose,  while 
it  permits  it  to  enter  the  lower  pharynx  freely.  A  slight  escape 
through  the  mouth,  around  the  tube,  is  negligible  but  usually  there 
is  none.  The  pharyngeal  tube  also  has  a  hole  through  which  a 
stomach  tube  (size  33  French)  may  be,  and  preferably  should  be, 
introduced,  to  permit  the  escape  of  any  air  reaching  the  stomach. 
A  respiratory  valve  is  inserted  in  the  connecting  hose.  This  valve 
is  regulated  by  the  operator,  alternately  allowing  an  inspiratory 
blast  and  the  escape  of  expiratory  air,  A  large  rubber  bag  is  in- 
terpolated between  the  valve  and  the  source  of  pressure.  A  T-tube 
with  a  clamp-screw  on  its  free  rubber  end  is  interpolated  between 
the  respiratory  valve  and  the  pharyngeal  tube;  this  regulates  the 
amount  of  air  intake.  A  padded  wooden  board  is  used  to  compress 
the  abdomen  by  means  of  belts.  This  prevents  the  entrance  of  air 
into  the  stomach.  It  may  thus  he  used  to  supplement  the  stomach 
tube,  or  either  may  be  used  alone,  depending  on  circumstances. 
A  further  advantage  is  claimed  for  the  board,  that  its  use  drives 
blood  from  the  splanchnic  area  toward  the  heart.  In  applying  the 
apparatus,  the  tongue  is  pulled  ou1  by  forceps,  and  after  the 
pharyngeal  tube  has  been  inserted,  the  tongue  is  tied  to  it  by  means 
of  tape.  This  prevents  the  tongue  and  glottis  from  falling  back, 
and  also  keeps  the  tube  in  place. 

This  method  has  been  reported  to  be  very  efficient,  and  was  rec- 
ommended by  the  Commission. 

Intralaryngeal  Insufflation. — Among  the  devices  for  effecting  in- 
tralaryngeal  insufflation  are  the  Fell  O'Dwyer  apparatus,  with  bel- 
lows; and  the  apparatus  devised  by  Matas,12  consisting  of  a  modi- 
fied O'Dwyer  cannula  connected  with  a  graduated,  adjustable 
pump  for  injecting  the  air.  but  with  no  return  suction. 

Intratracheal  Insufflation  of  Meltzer  and  Auer. — Meltzer  consid- 
ers intratracheal  insufflation  the  most  reliable  method  of  artificial 
respiration:  and  its  use  has  been  recommended  wherever  possible. 
An  endotracheal  tube  is  introduced  instead  of  the  pharyngeal  tube, 
otherwise  the  same  apparatus  may  he  used. 

As  to  the  comparative  efficacy  of  the  manual  and  the  mechanical 
modes  of  artificial  respiration,  the  claims  are  somewhat  conflicting. 
The  best  authorities,  however,  hold  that  in  cases  in  which  natural 
respiration  has  ceased  but  the  heart  still  beats,  artificial  respira- 
tion by  apparatus  (pump  or  bellows)  will  maintain  life  more  easily 
and  much  longer  than  employment  of  either  of  the  two  most  widely 


ARTIFICIAL    RESPIRATION  349 

used  manual  methods,  the  Silvester  and  the  Schafer.13  The  weak 
point  of  the  compression  methods  is  the  low  ventilation,  which 
decreases  as  the  muscles  of  the  body  lose  tonus.14  The  inflation 
methods  unquestionably  produce  greater  ventilation. 

For  the  manual  method,  a  noted  physiologist13  says:  "I  have  a 
strong  impression  that  during  the  first  minute  after  the  cessation 
of  respiration  (in  anesthesia)  the  administration  of  manual  arti- 
ficial respiration  is  more  effective  than  that  by  means  of  a  pump 
or  bellows,  the  reason  apparently  being  that  a  slight  assistance  is 
given  to  the  heart  and  circulation  by  the  manual  method  which  is 
not  afforded  by  mere  changes  of  air  pressure  in  the  lungs.  Cer- 
tainly both  in  the  laboratory  and  operating  room,  the  immediate 
application  of  manual  artificial  respiration  is  effective  in  restoring 
normal  breathing."  The  objection  has  also  been  raised  against  in- 
flation methods  that  they  may  injure  the  lungs  by  the  violent  as- 
piration.7' 12  Keith15  objects  that  inflation  is  not  physiologic,  i.  e., 
does  not  correspond  to  the  normal  mode  of  producing  breathing. 
He,  however,  states:  "My  mind  is  open  to  the  conviction  that  the  an- 
cient method  of  mouth-to  mouth  insufflation  with  expiratory  com- 
pression of  the  chest  may  not  prove  more  effective  than  either 
Silvester  or  Schafer  Methods." 

Laborde's  Tongue  Traction. — This  procedure  is  a  valuable  agent 
in  reestablishing  respiration.  In  anesthetic  accidents,  simple  trac- 
tion on  the  tongue  a  few  times  may  restore  breathing,  acting  in 
such  cases  by  lifting  the  epiglottis  and  thus  preventing  its  occlud- 
ing the  larynx. 

Laborde's  traction  is  executed  thus:  Grasp  the  tongue  deeply 
s.o  that  the  entire  organ  is  acted  on,  draw  it  out  forcibly  and 
sharply,  then  relax  suddenly  and  completely.  Do  this  at  a  rate  of 
about  fifteen  times  a  minute.  This  method  acts  by  inducing  reflex  ac- 
tion on  part  of  the  diaphragm.  Laborde  traced  the  impulse  through 
the  glossopharyngeal  and  lingual  nerves  to  the  respiratory  center,  and 
thence  to  the  phrenic  and  other  respiratory  nerves.  The  method 
is  a  valuable  adjunct  to  the  use  of  artificial  respiration  proper. 

Stimulation  of  the  Circulation 

Artificial  respiration  acts  as  a  circulatory  stimulant  by  sufficient 
oxygenation  of  the  blood ;  the  contractility  and  conductivity  of  the 
cardiac  muscle  are  increased  and  the  heart  picks  up. 


350  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

Heart  Massage 

Indirect  or  Extrathoracic  Massage. — This  procedure  is  often  a 
valuable  adjunct  to  artificial  respiration.  The  massage  is  executed 
by  rhythmical  compression  of  the  thorax  over  the  heart  by  means 
of  the  hands.  With  some  of  the  manual  methods  of  artificial  res- 
piration heart  massage  may  readily  be  incorporated  into  the  ex- 
piratory maneuver,  e.  g..  in  the  Silvester-Brosch  method.  Mas- 
sage has  also  been  done  from  the  abdominal  cavity  through  the 
diaphragm. 

Direct  or  Intrathoracic  Massage. — This  method  is  much  more  ef- 
fective, but  is,  of  course,  to  be  considered  a  last  resort  on  account 
of  the  danger  of  the  surgical  procedure,  of  mechanical  injury  to 
the  heart,  and  of  the  risk  of  infection.  In  anesthetic  accidents  the 
success  of  the  method  has  been  indifferent   (Stewart). 

Respiratory  Stimulation 

Sodium  Cyanide. — Recently  Loevenhart  and  associates16  have  se- 
cured strikingly  good  results  in  the  use  of  sodium  cyanide  as  a 
respiratory  stimulant  in  respiratory  failure  due  to  increased  in- 
tracranial pressure,  deep  chloroform  and  ether  anesthesia,  and  some 
other  conditions.  The  drug  is  administered  by  slow  intravenous  in- 
jection of  the  fiftieth  normal  solution  (0.1  per  cent).  Response  is 
quick.  The  injection  must  be  properly  controlled  and  the  patient 
be  under  observation.     The  method  is  very  promising. 

Electricity. — The  use  of  a  faradic  current  for  resuscitation  pur- 
poses has  been  shown  to  be  useless  and  may  even  be  harmful.8 

Adrenalin. — Adrenalin  injected  intravenously  is  said  to  be  use- 
ful in  circulatory  failure.  Experimentally,  Crile  and  Dolley  se- 
cured good  results  by  intracarotid  injection  of  adrenalin  in  saline 
infusion,  directed  toward  the  heart,  combined  with  artificial 
respiration  and  indirect  heart  massage,  in  cases  of  complete  heart 
failure.  Crile  has  used  the  method  successfully  on  human  beings. 
There  are  others  who  do  not  approve  the  method.2 

Oxygen  Inhalation.—  Compressed  oxygen  is  widely  used  as  an 
adjuvant  to  the  various  methods  of  artificial  respiration.  Objec- 
tion has  been  raised  to  prolonged  administration  of  pure  oxygen. 

Position. — The  Trendelenburg  posture  has  been  advocated  except 
when  the  face  is  cyanosed.  It  has  also  been  cautioned  against  in 
persons  with  large  abdomens,  owing  to  the  pressure  of  abdominal 
contents  on  the  diaphragm.  Application  of  heat,  by  hot-water  bot- 
tles and  hot  blankets,  is  useful.     Friction  of  limbs,  slapping  of  the 


ARTIFICIAL   RESPIRATION  351 

body  or  face  with  a  towel  wrung  out  of  ice  water,  forcible  dilata- 
tion of  the  sphincter  ani,  mechanical  and  chemical  (ammonia) 
stimulation  of  mucous  membranes  of  the  nose,  of  the  precordial  or 
pudic  regions  or  of  the  soles  of  the  feet,  are  useful  forms  of  stimu- 
lation and  should  not  be  neglected  as  adjuvants  to  the  other  meth- 
ods used. 

Full  credit  is  due  Adolph  Rumreich  for  having  abstracted  all  the 
literature  to  which  reference  is  made  in  this  chapter. 

Bibliography 

iCarrell  and  Guthrie:     Am.  Med.,  1908,  x. 

sCrile  and  Dolley:     Jour.  Exper.  Med.,  1906,  viii;  ibid.,  1908,  x. 

sStewart,  Guthrie,  Burns  and  Pike:  Jour.  Exper.  Med.,  1908,  x;  Am.  Jour. 
Physiol.,   1908. 

4Aron,  E.:     Berl.  kliu.  Welmsehr.,  Feb.  8,  1915. 

sHerter,  G.;  Deutsch,  med.  Wchnschr.,  1905.  i. 

eEysselsteijn:   Die  Meth.   der  Iviinst  Stm.  Julius   Springer,  Berlin,  1912. 

"Eeport  of  the  Committee  on  Besuseitation  from  Mine  Gases,  Cannon,  Crile, 
Erlanger,  Henderson  and  Meltzer:  Tech.  Paper  77,  Bureau  of  Mines,  Dept. 
of  Interior. 

sHare:     Keen's  Surgery,  1911.  v. 

sHare:  Bull.  Johns  Hopkins  Hosp.,  1895. 
icMeltzer:   Jour.  Am.  Med.  Assn.,  1913,  lx. 
"Meltzer:  Med.  Bee.,  Xew  York,  July  7,  1917,  xcii. 
12Matas,  B.,:  Jour.  Am.  Med.  Assn.,  1902,  iii. 
isHenderson,  Yandell:     Jour.  Am.  Med.  Assn.,  Julv,  1916,  Ixvii. 
"Liljestrand :     Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1913,  xxvi. 
i5Keith:   Hunterian  Lectures,  Lancet,  London,  1909. 
isLoevenhart,  Lorenz,  Martin  and  Malone:  Arch.  Int.  Med.,  1918,  xxi. 


CHAPTER  XLIII 

POSTOPERATIVE  FEEDING 
By  J.  W.  Larimore,  St.  Louis,  Mo. 

The  problems  of  postoperative  feeding  have  for  the  result  of 
their  solution  the  maintenance  of  body  nutrition  during  a  period 
of  acute  physiologic  disturbance,  and  frequently,  later,  through 
a  period  of  physiologic  adjustment.  It  is  often  necessary  to  hold 
in  abeyance  for  variable  periods  all  energy  intake  and  leave  the 
body  to  continue  on  its  own  resources,  which  alone  introduces  all 
the  alterations  of  normal  metabolism  incident  to  partial  or  com- 
plete starvation. 

The  first  problem  is  the  early  resumption  of  food  intake.  Dietet- 
ics of  postoperative  conditions  is  based  upon  the  fundamental  facts 
of  nutrition  in  an  effort  to  approximate  or  maintain  full  nutrition, 
as  well  as  may  be  possible  under  the  limitations  of  disturbed  physi- 
ology. The  maintenance  of  nutrition  during  a  postoperative  course 
is  quite  as  great  a  gain  for  the  patient,  as  has  been  the  maintenance 
of  adequate  nutrition  in  those  infectious  fevers,  where  formerly 
medical  treatment  included  extreme  starvation.  The  process  of  re- 
pair and  the  resistance  of  the  patient  are  augmented  and  the  con- 
valescence and  regaining  of  strength  greatly  shortened.  Adequate 
nutrition  can  at  no  time  be  withheld  without  detriment  to  the  body 
functions  and  in  operative  conditions  where  suspension  of  diet  is 
unavoidable,  the  early  resumption  (Fig.  52)  of  partial  or  adequate 
nutrition  is  urgent,  and  offers  the  greatest  aid  to  the  return  of 
normal  physiologic  adjustments  and  to  the  successful  outcome  of 
the  surgical  measures. 

Physiologic  disturbances  result  from  various  fundamental  causes 
often  irrespective  of  operative  procedures.  The  pathology  may  be 
such  as  to  alter  metabolism  or  to  present  mechanical  difficulties 
to  ingestion  and  digestion,  these  latter  not  always  being  entirely 
relieved  by  the  operation.  The  postoperative  feeding  must  neces- 
sarily be  adjusted  to  these  uncorrected  conditions.  A  diabetic 
should  not  have  and  could  not  utilize  the  carbohydrates  which  are 
otherwise  of  immediate  preference  in  postoperative  feeding. 
Stenosis  of  the  esophagus,  of  course,  is  not  relieved  by  gastrostomy. 
The  physiology  is  further  altered  by  the  invasion  of  the  disease  into 

352 


POSTOPERATIVE    FEEDING 


353 


various  organs  necessary  to  the  digestive  process,  or  to  interme- 
diary metabolism.  These  considerations  influence  more  the  charac- 
ter of  postoperative  diet  than  its  manner  or  degree.  Anesthesia 
disturbs  the  mechanical  functions  of  the  gastrointestinal  tract  and 
the  degree  of  this  disturbance  determines  the  time  of  resuming  feeding 
and  also  the  amount  of  feeding.  General  anesthesia  also  has  a 
definite  effect  upon  intermediary  metabolism,  promoting  those  con- 
ditions which  give  rise  to  acidosis  with  acetonuria.  or  acetonemia. 
Local  anesthesia  has  no  great  or  direct  effect  upon  the  mechanics 
of  the  gastrointestinal  tract. 

The  physiologic  processes  are  further  disturbed  by  postoperative 


Fig.    52. — -A   convenient   scheme   for   early   administration    of   fluids. 


complications,  among  which  the  chief  are  infections,  acute  cardiac 
dilatation,  acute  dilatation  of  the  stomach,  intestinal  ileus,  hemor- 
rhage, and  shock,  also  pneumonia  and  cardiac  disturbances. 

The  nature  of  the  operation,  of  course,  is  most  important,  in  an- 
ticipating or  determining  the  nature  and  degree  of  the  dietetic 
problems.  Minor  surgery  seldom  necessitates  any  postoperative  con- 
sideration of  diet.  Major  surgery  will  vary  in  its  influence  upon 
nutritional  factors  according  as  it  involves  structures  removed  from 
the  enteron,  or  as  it  may  be  upon  organs  collateral  to  the  enteron, 
or  upon  the  tract  itself. 


354  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

The  extent  of  the  starvation  period  which  is  necessary  fol- 
lowing- many  operations  is  necessarily  determined  by  the  physi- 
ologic disturbances  which  have  resulted  and  which  would  prohibit 
or  limit  feeding.  The  manner  in  which  the  patient  endures  this 
starvation  period,  especially  if  it  he  extended,  will  depend  upon 
his  preoperative  nutritive  condition.  This  often  has  been  greatly 
impaired  as  the  direct  result  of  the  pathologic  and  physiologic 
status  of  the  disease.  It  is  also  determined  by  the  manner  of  pre- 
operative feeding  which  often  has  been  practically  a  longer  or 
shorter  period  of  partial  starvation,  frequently  to  the  point  of  es- 
tablishing a  marked  acetonemia.  Often  one  or  several  days  of 
complete  starvation  have  preceded  the  operation.  Such  conditions 
naturally  lessen  the  facility  with  which  the  patient  endures  a  post- 
operative period  of  complete  or  partial  starvation.  It  is  also  proba- 
ble that  the  acidosis  and  the  increased  H-ion  concentration  of  the 
blood  resulting  from  the  preoperative  starvation  increases  the  det- 
rimental effects  <>f  general  anesthesia  and  promotes  those  conditions 
which  simulate  or  may  become  actual  shock.  It  is  desirable  that 
prior  to  operation  the  nutrition  <>f  the  patient  should  receive  careful 
attention  and  be  raised  to  the  highest  possible  level,  continuing  feed- 
ing even  to  a  few  hours  prior  to  the  operation.  Other  preoperative 
measures  in  management  and  preparation  have  their  bearing  upon 
postoperative  feeding,  especially  those  directed  in  the  condition  of 
the  intestines.  The  colon  should  be  empty.  The  manner  of  accom- 
plishing this  is  important.  Purgatives  accomplish  the  result  by  a 
mosl  violent,  unnatural  action,  and  they  Leave  the  intestines  in  a 
condition  of  marked  peristaltic  disturbance,  and.  as  a  collateral 
effect,  disturb  the  vasomotor  and  other  controls  of  the  circulation 
of  both  blood  and  lymph.  For  such  a  result  of  purgation  to  be 
presenl  at  the  time  the  abdomen  is  opened  increases  the  tendency 
to  shock  and  intestinal  paresis,  which  may  resull  from  trauma  and 
from  the  general  anesthesia.  It  is  best  that  the  emptying  of  the 
colon  by  purgation  should  be  accomplished  a  few  days  prior  to  op- 
eration. Parallel  case  series  have  shown  that  purgation  just  prior 
to  operation  increases  the  ballooning  of  the  intestines  and  the  diffi- 
culty of  keeping  them  within  the  abdomen  at  laparotomy,  and  also 
greatly  increases  the  frequency  of  postoperative  lnis  pains  and 
cramps.  Animal  experiments  have  shown  thai  gas  absorption 
as  normally  occurs  fails  in  the  purged  intestine.  In  most  e;ises 
where  the  colon  needs  attention,  immediately  prior  to  the  op- 
eration, a  large  enema  is  usually  effectual,  and  is  the  only  measure 


POSTOPERATIVE    FEEDIXG  355 

without  undesirable  effects  at  laparotomy.  It  is  also  very  adequate 
for  all  other  operations. 

Preoperative  measures  are,  of  course,  not  possible  in  emergency 
operations.  In  emergency  laparotomies  a  large  cleansing  enema, 
(when  allowable)  is  the  most  satisfactory  preparation  of  the  colon. 
In  elective  operations  sufficient  time  should  be  taken  (from  two  to 
seven  days,  or  even  more;  to  secure  the  best  possible  state  of  nu- 
trition and  gastrointestinal  adjustment.  With  pyloric  stenosis  a 
few,  or.  in  the  lesser  grades,  several  days  of  careful  feeding  and 
lavage  once  or  twice  daily  will  accomplish  a  considerable  improve- 
ment in  nutrition,  and  a  lessening  of  the  edema  and  the  atony 
of  the  stomach  walls,  which  will  be  very  satisfactory  to  the  op- 
erator and  will  facilitate  postoperative  gastric  functioning.  These 
days  will  allow  for  cleansing  of  the  gastrointestinal  tract  by  a 
laxative  and  enema  and  the  return  of  normal  peristaltic  stability. 
If  constipation  has  been  usual  with  the  patient,  the  use  of  small 
enemas  of  magnesium  sulphate,  three  ounces  of  the  saturated  solu- 
tion, will  assist  not  only  in  the  emptying  of  the  colon,  but  will  help 
correct  also  any  spasticity  which  may  be  the  cause  of  the  constipa- 
tion, and  which  would,  postoperatively,  be  a  factor  in  gas  retention. 

Nutrition  should  be  brought  to  an  adequate  level,  sufficient  to  re- 
lieve any  acetonemia,  which  may  have  resulted  from  the  patient's 
limitations  of  diet,  self-imposed  or  otherwise  advised.  On  the  day 
prior  to  the  operation  it  is  desirable  to  force  carbohydrate  foods. 
This  is  an  effort  to  hyperglycogenize  the  patient.  I  have  noted  in 
cases  of  rather  extreme  malnutrition,  where  a  sufficient  time  could 
not  be  taken  to  correct  the  condition,  or  when  the  pathology  obvi- 
ated correction,  that  intravenous  glucose  injections  gave  splendid 
results  in  lessening  the  postanesthetic  gastric  disturbance  and  the 
urinary  acidosis. 

It  is  the  aim  of  postoperative  feeding  to  attain  as  rapidly  as  is 
safe  the  necessary  energy-requirement  for  the  basal  metabolism  of 
a  patient  under  such  conditions.  The  range  of  this  energy  require- 
ment will  be  from  1000  to  2000  calories.  (By  a  calorie  is  meant  the 
amount  of  heat  necessary  to  raise  one  liter  of  water  through  one 
degree  of  centigrade  temperature.)  This  will  vary  according  to 
many  factors:  (1)  age;  (2)  according  to  the  nutritive  condition  of 
the  patient,  whether  emaciated,  thin,  robust,  or  fat;  (3)  according 
to  any  febrile  condition  present ;  and  (4)  according  to  the  state  of 
rest,  whether  sleeping,  nervous,  restless,  etc.  One  effective  guide 
to  the  adequacy  of  any  diet  is  the  acetone  reaction  of  the  urine, 


356  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

which  will  be  positive  when  the  diet  is  less  than  the  starvation  level. 
The  total  number  of  calories  that  may  be  given  is,  of  course,  not 
limited  to  the  minimum  energy  needs.  The  patient  should  be  given 
a  very  large  energy  supply  when  it  becomes  safe  to  do  so,  in  a  diet 
adjusted  to  the  postoperative  gastrointestinal  situation  and  to  any 
general  condition.  Ulcer  of  the  stomach  or  duodenum  and  gastro- 
enterostomy should  be  protected  from  recurrence  of  activity  if 
the  original  ulcer  has  been  untouched,  or  from  the  development  of 
a  stoma  or  jejunal  lesion.  Ileostomy  necessitates  providing  the  op- 
portunity for  the  terminal  ileum  to  assume  the  functions  of  the 
colon,  and  this  is  in  large  part  done  with  dietetic  measures.  Such 
general  conditions  as  diabetes,  cardio-renal  hypertension  and  gout 
must  be  considered  in  outlining  the  diet.  The  immediate  postoper- 
ative problem  is,  however,  to  secure  adequate  energy  intake.  Fat 
is  equivalent  per  gram  to  9.3  calories;  protein  to  4.1  calories,  and 
carbohydrate  to  4.1  calories. 

Carbohydrate  is  the  type  of  food  preferable  in  postoperative  diet. 
It  is  quickly  absorbed  and  easily  available  for  energy.  Dextrose 
itself  is  absorbed  within  30  minutes  (there  being  no  gastric  motor 
delay)  and  is  immediately  available  for  energy.  Protein,  by  a  spe- 
cific dynamic  action,  raises  the  level  of  basal  metabolism  and  in- 
creases the  heat  output  of  the  body,  and  adds  very  considerably  to 
the  energy  requirement.  It  is  desirable  only  in  moderate  quantities. 
Protein  is  seen  clinically  to  afford  strength  to  a  patient  which  can  not 
be  secured  by  a  diet  otherwise  calorically  adequate.  This  is  perhaps 
directly  associated  to  its  specific  dynamic  action.  Fat  because  of 
its  high  caloric  value  is  of  great  advantage  in  securing  high  energy 
intake  in  a  small  bulk.  It  is  often  essential  to  calculate  the  per- 
centages and  caloric  values  of  the  diet.  For  anyone  who  does  not 
use  such  data  daily,  and  therefore  does  not  hold  it  in  mind,  it  may 
be  readily  found  in  any  book  on  general  dietetics.  A  guess  at 
dietetic  values  can  easily  be  wrong,  and  Only  by  careful  calculation 
can  one  be  sure  of  adequate  nutrition.  In  protracted  and  difficult 
cases,  where  a  progressive  increase  in  the  diet  is  impossible,  accurate 
calculation  must  be  done  to  have  any  sure  conception  of  the  nutri- 
tional situation. 

Fluid  is  volumetrically  the  greatest  of  the  body's  requirements, 
and  this  is  greatly  increased  by  postoperative  disturbances.  Water 
is  lost  by  the  body,  not  alone  by  the  mine,  but  also  through  the 
skin  and  lungs,  and  this  normally  amounts  to  from  BOO  to  800  c.c.  in 
a  day.     The  loss  of  water  vapor  through  the  lungs  and  skin  during 


POSTOPERATIVE    FEEDING  357 

and  after  anesthesia  is  very  greatly  increased.  This  dehydration 
of  the  patient  occurs  not  alone  from  water  lost,  but  also  because  all 
fluid  intake  is  stopped  or  limited.  The  loss  of  fluids  is  further  aug- 
mented by  the  creation  of  any  drainage  fistula?,  especially  biliary. 
A  postoperative  diarrhea  greatly  increases  the  loss  by  preventing 
the  body 's  water  economy  which  occurs  by  resorption  in  the  cecum. 
Postanesthetic  vomiting  may  account  for  a  great  loss  of  fluids. 

The  measures  of  postoperative  feeding  may  be  divided  into  those 
directed  to  the  immediate  and  acute  situation,  and  those  directed  to 
the  more  remote  problems.  The  immediate  condition  is  in  greater 
part  the  result  of  surgical  wounds  of  the  gastrointestinal  tract  and 
of  the  anesthetic.  The  great  amount  of  water  lost  through  the 
skin  and  lungs  creates  a  greater  or  less  degree  of  dehydration, 
which  in  any  event  it  is  important  to  quickly  relieve.  At  times  re- 
lief becomes  urgently  necessary.  On  the  other  hand,  in  the  pres- 
ence of  circulatory  disturbances,  especially  in  the  aged,  and  even 
when  general  dehydration  is  fairly  extreme,  there  may  be  such  a 
plethora  of  the  lesser  circulation  as  to  contraindicate  the  addition 
of  fluids  by  any  other  manner  than  oral  administration.  Water  may 
be  given  by  proctoclysis,  hypodermoclysis  or  even  intravenously. 
Should  it  be  given  intravenously,  it  is  a  great  advantage  to  give  a 
glucose  solution,  and  thereby  add  a  large  energy  quotient.  This 
solution  may  range  in  percentage  from  five  to  twenty  and  should  be 
made  with  anhydrous  dextrose.  Two  to  four  per  cent  of  sodium 
bicarbonate  may  be  added  if  desired.  It  is  also  desirable  that  the 
proctoclysis  contain  glucose.  Three  to  five  per  cent  glucose  solu- 
tion is  borne  by  the  rectum  about  equally  as  well  as  tap  water  or 
saline.  There  is  seldom  any  contraindication  to  allowing  water  in 
small  amounts  by  mouth  immediately  after  operation.  Even  with 
vomiting,  fluid  intake  will  often  have  a  quieting  effect,  and  if  not, 
it  will  add  greatly  to  the  ease  of  vomiting,  and  will  accomplish  a 
spontaneous  lavage  of  the  stomach.  However,  unless  relief  is  quickly 
gained  more  direct  measures  must  be  used  and  especially  in  laparot- 
omized  cases. 

Gastric  lavage  should  be  used  freely  in  the  hours  immediately 
postoperative,  and  is  perhaps  one  of  the  most  effectual  measures  in 
returning  the  stomach  to  the  function  where  it  will  receive  and  al- 
low the  progression  of  food.  This  is  especially  true  after  stomach 
operations.  These  stomachs  may  retain,  even  without  any  retching 
or  vomiting,  and  with  perhaps  nothing  more  than  a  slight  nausea, 


358  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

very  great  amounts  of  hyperacid  secretion  mixed  with  old  blood. 
Such  retention  increases  the  possibility  of  acute  dilatation. 

The  progression  in  diet  should  be  as  rapid  as  is  safe.  Usually  by  the 
end  of  the  third  day  all  acute  symptoms  are  past.  The  distention  of 
the  intestines  postoperatively  often  gives  great  hindrance  to  in- 
crease in  diet.  Tympanitis  is  especially  distressing.  It  interferes 
with  proctoclysis  and  increases  nausea  and  retching.  The  use  of 
small  enemas  of  magnesium  sulphate  as  has  been  described  above 
is  very  effectual  in  relieving  the  condition.  When  it  is  slight  and 
unaccompanied  by  nausea  and  retching,  the  postoperative  diet 
should  not  be  stopped.  Rather,  the  entrance  of  the  food  into  the 
stomach  is  often  a  positive  aid  in  the  establishment  of  the  normal 
reflexes  and  tonus,  which  will  overcome  the  tympanitis,  assist  in 
the  release  of  flatus,  and  secure  the  first  postoperative  defecation. 
There  are  those  cases  which  upon  each  intake  of  food  or  fluid  have 
an  urgent  desire  for  defecation  or  even  intractable  diarrhea.  This 
is  a  disturbance  in  the  autonomic  nervous  system  and  is  controlled 
by  liberal  use  of  atropine  to  its  physiologic  limits. 

Late  after  operation,  vomiting  is  at  times,  even  when  the  enteron 
has  been  untouched,  perniciously  prolonged  without  discoverable 
cause.  It  is  apparently  intractable,  and  nutrition  suffers  greatly. 
When  there  is  no  other  accompanying  condition  which  contraindi- 
cates,  feeding  should  be  continued  and  forced  with  a  selection  of 
the  simpler  mobile  foods  and  an  avoidance  of  cellulose  roughage. 
Such  vomiting  is  usually  on  a  neurotic  basis.  It  gives  rise  to  an 
acetonemia  which  increases  all  general  nervous  disturbances.  Usu- 
ally by  persistent  feeding  with  consequent  relief  of  the  acetonemia 
and  by  the  use  of  sedatives,  this  vomiting  can  be  eventually  con- 
trolled, and  the  patient  returned  to  a  normal  diet.  It  is  in  these 
cases  so  often  that  rectal  feeding  is  used.  The  absorption  of  other 
than  the  sugar  content  of  any  nutritive  enemas  is  very  doubtful. 
The  use  of  other  than  the  glucose  proctoclysis  in  rectal  feeding  only 
clouds  the  estimation  of  the  energy  supply  that  is  being  secured 
and  too  often  allows  the  assumption  that  greater  help  is  being  at- 
tained than  is  actually  the  case. 

The  remote  problems  of  postoperative  diet  are  directed  to  those 
conditions  which  will  assist  in  a  complete  cure  of  the  patient,  such 
as  the  relief  of  constipation  after  appendectomies  or  hemorrhoid- 
ectomies; the  fattening  cure  after  nephropexy;  the  careful  pre- 
scription of  a  nephritic  diet  following  other  kidney  operations;  and 
in  the  presence  of  a  biliary  or  pancreatic  fistula,  the  avoidance  of 


POSTOPERATIVE   FEEDING 


359 


those  articles  or  types  of  food,  which  need  for  their  digestion  and 
absorption  the  secretions  which  are  lost  to  the  body. 

The  following  postoperative  diet,  which  is  for  a  general  applica- 
tion after  laparotomies  including  gastroenterostomy,  is  very  con- 
servative, and  when  used  routinely  has  given  large  advantage  and 
satisfaction.  Often  it  may  be  increased  more  rapidly  than  is  indi- 
cated. It  is  often  considered  very  unpalatable  by  the  patient,  and 
may  have  to  be  urged  as  a  necessary  measure  similar  to  medicines. 


Preparation : 


First   Day: 

(Day   of   Opera- 
tion) 

Second  Day: 


Postoperative  Diet 

In  addition  to  the  preoperative  diet,  which  should  continue 
to  and  include  on  the  evening  prior  to  operation  liberal 
liquid  nourishment,  give  3%  glucose  as  proctoclysis, 
continuing    from   noon   until   morning   after   operation. 

3%  glucose  as  proctoclysis.     Water,  small  sips,  ad  lib. 


Third    Day  : 


Fourth  Day: 


X  grains  of  Sodium  Citrate  in  II  ounces  of  water  every  3 

hours. 
Junket    or   oatmeal   jelly,   I    ounce    at    a   feeding,    every    3 

hours;   to  alternate  with  Sodium  Citrate  Solution. 
Continue  3%  glucose  as  proctoclysis. 

Feed   every  2  hours,  alternating  Junket,   oatmeal  jelly,   or 
Bulgarian  milk  and  cream    (2/3  and  1/3)  ;   II  ounces 
at  a  feeding.      (One  or  two  feedings  during  the  night 
if  awake.) 
Feed  every  2  hours.     Same  as  on  third  day,  plus  custard, 
blane-niange ;   gelatine,  served  with  sugar  of  milk  and 
cream. 
One  seven-minute  egg. 
7:00  A.M.     One-seven-minute  egg. 
9:00  A.M.     Oatmeal  jelly. 
11:00  A.M.     Custard. 
1:00  P.M.     Junket, 
3:00  P.M.     Blanc-mange. 
5 :  00  P.  M.     Bulgarian  milk. 
7:00  P.M.     Gelatine. 
(This   order  may  be  rearranged.) 
Increase   cpiantity   to    IV   ounces   with   feedings   2%   hours 

apart.     Same  articles. 
Junket,   oatmeal  jelly,   custard,  blanc-mange,   and  gelatine, 
to  be  made  up  with  sugar  of  milk  (no  cane  sugar  used 
in  list). 

Operations  about  the  mouth,  head,  and  mediastinum,  even  when 
of  a  minor  nature,  may  give  mechanical  difficulties  to  feeding.  This 
may  necessitate  the  use  of  a  tube  for  the  introduction  of  food  into 


Fifth,   Sixth   and 
Seventh  Days: 


360  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

the  stomach.  Infections  accompanying  or  following  surgical  condi- 
tions introduce  dietetic  problems,  chiefly  because  of  the  effect  of  the 
resulting  toxemia  upon  gastric  secretions  and  motility.  Carlson 
states  that  experimental  infections  are  shown  to  cause  complete 
atony  and  absence  of  gastric  hunger  contractures  and  that  bacterial 
toxins  may  depress  the  motor  mechanism  of  the  stomach  directly, 
lower  the  vagus  tonus,  augment  inhibitory  reflexes,  or  induce  ex- 
cessive secretion  of  epinephrin.  Cannon  has  observed  that  infec- 
tions also  depress  the  digestive  peristalsis  of  the  stomach  and  in- 
testines in  cats. 

In  the  presence  of  such  inhibitions  from  toxemia  the  size  and 
character  of  the  feeding  must  be  of  the  simplest  kind  to  obviate 
accumulation  in  the  stomach  and  its  attendant  results;  distention, 
belching,  nausea  and  vomiting,  and  flatulence.  This  toxemia  may 
even  be  a  basis  for  an  acute  dilatation  of  the  stomach. 

In  acute  dilatation  of  the  stomach  following  anesthesia,  rest  of 
the  organ  is  imperative,  and  this  will  prohibit  food  and  fluids  by 
mouth.  In  all  cases  of  persistent  vicious  vomiting,  often  with  re- 
sulting acute  dilatation,  lavage  is  the  greatest  help.  This  should 
be  used  freely,  and  will  give  the  patient  more  comfort  and  the  sur- 
geon greater  protection  against  postoperative  gastric  conditions 
than  any  other  measure.  In  dilatation  of  the  stomach  in  soldiers 
due  to  anesthesia  and  shock  and  to  toxemia,  I  have  used,  with 
very  great  success,  the  gastroduodenal  tube  for  constant  and  in- 
terrupted drainage.  The  tube  is  retained  in  the  stomach  and,  at 
first,  constanl  drainage  is  maintained,  allowing  small  amounts  of 
water  by  month  for  lavage.  When  this  lavage  water  only  is  re- 
covered and  no  additional  quantity  due  to  secretion,  then  small 
hourly  feedings  of  a  simple  nutrient  fluid  may  be  begun,  and  the 
tube  clamped.  The  stomach  is  drained  prior  to  each  feeding.  Com- 
parison of  the  quantities  given  and  recovered  will  indicate  the  de- 
gree of  motor  recovery  of  the  stomach  and  determine  when  tube 
feeding  and  drainage  may  be  discontinued.  After  shock,  even  water 
will  be  contraindicated.  The  engorgemenl  which  exists  in  all  of 
the  splanchnic,  area  will  allow  no  absorption,  rather  we  may  expect 
a  secretion  of  thuds  due  directly  to  the  engorgement.  This  will  also 
necessitate  Lavage.  It  is  doubtful  whether  in  these  cases  proctoclysis 
is  accomplished,  due  to  a  similar  lack  of  absorption.  The  only 
routes  for  administering  fluids  in  a  condition  of  shock  are  subcu- 
taneous or  intravenous. 

Peritonitis,  when   acute  and  general,  indicates  rest   of  the  intes- 


POSTOPERATIVE    FEEDING  361 

tinal  tract  and  the  suppression  of  peristalsis.  The  general  rule  has 
been  to  avoid  for  long  periods  nutrition  and  fluid  by  mouth  and  to 
give  nutritive  enemas.  The  latter  doubtless  will  create  as  much 
peristaltic  unrest  as  will  bland  and  nonstimulating  fluids  by  mouth. 
It  must  be  remembered  that  the  infection  itself  has  inhibited  peri- 
stalsis. Often,  however,  associated  vomiting  will  prevent  oral  feed- 
ing. Flatulence  and  fermentative  processes  are  dangerous  and  the 
residue  starches  must  be  avoided.  Nutrition  becomes  imperative  if 
the  patient's  resistance  and  recuperative  powers  are  to  be  supported 
and  maintained.  The  surgical  postoperative  diet,  as  has  been  given, 
but  with  slower  progression,  can  be  used  to  advantage  in  this  con- 
dition. An  initial  starvation  period  of  48  hours  should  be  used,  but 
feeding  should  be  started  early  enough  and  in  sufficient  amount  to 
prevent  acetonemia,  which  is  the  first  indication  that  nutrition  is 
beginning  to  suffer.  In  localized,  acute  peritonitis  the  dietetic  prin- 
ciples are  the  same  as  in  general  peritonitis. 

In  chronic  peritonitis,  which  is  usually  of  tuberculous,  origin,  there 
is  often  an  accompanying  diarrhea,  perhaps  due  to  exudative  proc- 
esses and  perhaps  to  lack  of  absorption.  Depending  upon  the  de- 
gree of  this  disturbance,  the  food  must  be  more  or  less  residue  free. 
In  any  case  there  must  be  a  simple,  bland  diet.  Hypernutrition  is 
not  contraindicatecl.  Flatulence  and  the  distention  of  the  bowels 
are  to  be  avoided. 

In  cases  of  obstructive  jaundice  relieved  with  a  biliary  fistula, 
there  is  a  large  danger  jof  a  yellow  atrophy  of  the  liver  with  fatal 
termination.  The  liberal  use  of  carbohydrates  is  of  the  greatest 
service  not  alone  in  nourishing  the  patient,  but  in  the  protection  of 
the  hepatic  parenchyma.  The  enterol  digestion  of  carbohydrate  is 
more  complete  than  that  of  other  foods  where  there  is  a  partial  or 
complete  absence  of  bile  in  the  intestines,  and  the  liver  is  relieved 
of  its  metabolic  functions,  in  handling  fat  especially,  and  also  the 
protein  products.  The  carbohydrate  has  been  shown  to  have  a  di- 
rect protective  action.  The  postoperative  diet  of  gallstone  cases 
should  be  very  poor  in  fat,  and  obese  patients  should  be  urged  to  re- 
duce. The  hypercholesterinemia  which  is  present  in  these  cases  is 
thus  corrected. 


CHAPTER  XLIV 

REDUCTION  OF  OBESITY 
By  Willard  Bartlett  and  Alfred  Goldman,  St.  Louis,  Mo. 

The  postoperative  treatment  of  the  obese  is  of  especial  interest 
from  two  standpoints:  first,  directly,  by  aiming-  at  the  particular  or- 
gan or  region  involved  ;  second,  indirectly  by  building  up  the  general 
condition  of  the  patient.  The  treatment  of  obesity  is  of  importance 
after  abdominal  operations,  where  an  excessive  panniculus  and  sub- 
peritoneal fat  are  prone  to  produce  postoperative  hernia.  It  is  also 
of  importance  in  that  it  improves  the  cardiovascular,  the  respira- 
tory, the  digestive  systems,  the  smooth  working  of  which  is  es- 
sential to  a  good  recovery.  Moreover  it  seems  a  most  Logical  tiling  to 
start  the  treatment  of  such  a  condition  after  a  surgical  operation; 
first,  because  the  patient's  metabolism  is  of  oecessity  much  deranged, 
his  ingestion  considerably  diminished,  etc;  second,  because  a  rigid 
reduction  treatment  must  lie  carried  on  under  careful  supervision 
to  be  effective,  preferably  therefore  in  an  institution. 

It  is  essential  to  determine  when  a  reduction  is  indicated.  When 
this  is  determined  and  the  proper  methods  of  treatment  applied, 
then  a  reduction  will  strengthen  the  patient.  The  indications  have 
been  aptly  considered  in  this  class  of  cases  by  von  Noorden  and 
others. 

A  high  degree  of  obesity,1  which  may  be  arbitrarily  taken  as  70 
pounds  or  more  than  the  weight  corresponding  to  a  normal  indi- 
vidual of  the  same  height  is  always  to  be  considered  as  an  indication 
for  reduction.  In  children  and  in  the  aged,  one  should  be  careful 
in  advising  treatment. 

A  moderate  degree  of  obesity  I  40-70  pounds  over  weight)  is  an 
indication  for  reduction  in  the  young  and  middle-aged,  unless  there 
is  some  special  contraindication.  In  older  people,  as  a  rule,  it 
should  not  be  advised. 

A  slight  degree  of  obesity.  (20-40  pounds  over  weighl  I  is  not  an 
indication  for  treatment,  unless  there  is  a  tendency  for  the  condi- 
tion to  be  aggravated.  In  such  a  case,  reduction  can  be  made  very 
effective  with  slight   restrictions. 

Certain  special  conditions  call  for  a  reduction  core,  even  in  mild 
cases  of  obesity.    They  are  disease^  of  the  circulatory  system,  chronic 

362 


REDUCTION    OF    OBESITY  363 

bronchitis,  or  emphysema,  in  which  the  removal  of  an  excess  weight 
will  enlighten  the  burden  of  the  various  systems.  In  contracted 
kidney,  reduction  should  be  very  gradual.  Advanced  age  is  a 
contraindication.  Diabetics  and  gouty  individuals  do  better  when 
there  is  a  certain  degree  of  obesity.  The  same  may  be  said  of  cases 
of  pulmonary  tuberculosis. 

Any  rational  treatment  of  obesity  must,  of  course,  seek  to  do  one 
thing,  namely,  to  make  the  expenditure  of  energy  greater  than  the 
energy  intake  of  food.  This  means  that  the  body  makes  up  its  def- 
icit from  its  own  tissues,  and  as  is  well  known,  will  obtain  this 
chiefly  from  its  adipose  supplies. 

Obesity  may  be  due  to  many  various  causes.  Before  devising  a 
plan  of  treatment,  it  is  essential  to  obtain  an  accurate  account  of 
the  habits  of  the  individual,  for  treatment  must  be  adapted  to  fit 
the  cases.  If  there  is  an  outstanding  etiologic  agent,  this  should 
be  removed  first.  All  dietitians  consider  treatment  under  three 
heads :  dietetic,  mechanical  and  medicinal. 

1.  Diet. — All  rules  in  regard  to  dietary  measures  should  be 
based  on  caloric  feeding.  The  food  must  be  weighed  and  measured, 
at  least  at  first,  and  the  patient  must  be  accurately  weighed  at  short 
intervals. 

There  are  a  number  of  "systems"  in  vogue,  the  principal  ones 
being  those  of  Banting,  Ebstein,  Oertel,  and  von  Noorden.  In 
Banting's2  method,  sugar,  fats  and  starches  are  greatly  restricted; 
water  is  not  reduced,  and  alcohol  is  allowed.  This  system  with  its 
high  protein  content  and  small  amount  of  food  in  general,  has  been 
called  "unphysiologic  and  impractical." 

In  Ebstein 's3  system,  the  proteins  and  carbohydrates  are  dimin- 
ished and  fat  is  increased.  Ebstein  found  that  when  fat  forms  a 
large  element  in  the  diet,  a  feeling  of  satiety  is  readily  produced, 
so  that  the  total  food  contains  fewer  calories.  This  does  not  always 
hold  by  any  means,  since  the  patient  may  soon  cease  to  be  affected 
in  this  manner. 

Oertel's4  method  is  good  for  cases  of  obesity  with  weak  hearts. 
Oertel  allows  little  fat  but  more  protein  and  carbohydrate  than 
Ebstein.  "Water  is  greatly  diminished,  only  one  pint  of  free  water 
being  allowed,  and  one  pint  along  with  the  food.  His  diet-table 
follows : 

Carbohy- 

Albumia  Fat  drates  Calories 

Minimum  156  25  75  1100 

Maximum  170  45  120  1600 


364  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

The  following  is  an  illustration  of  Oertel's  dietary: 

Morning:  A  cup  of  coffee  or  tea  with  a  little  milk  about  six  ounces 
(178  c.c.)  altogether;  bread,  three  ounces  (93  gm.). 

Noon:  Three  to  four  ounces  (90  c.c.  120  c.c.)  of  soup;  7-8  ounces 
(218  gm.  to  248  gm.)  of  roast  beef,  veal,  game,  or  poultry;  salad  or  a 
light  vegetable;  a  little  fish,  1  ounce  (32  gm.)  of  bread  or  farinaceous 
pudding;  3-6  ounces  (93-186  gm.)  of  fruit  for  dessert.  No  liquids 
at  this  meal,  as  a  rule;  but  in  hot  weather  6  ounces  (178  c.c.)  of  light 
wine  may  be  taken. 

Afternoon:  Six  ounces  (178  c.c.)  of  coffee  or  tea,  with  as  much 
water.    An  ounce  of  bread. 

Evening:  One  or  two  soft-boiled  eggs,  1  ounce  (32  gm.)  of  bread, 
perhaps  a  small  slice  of  cheese,  a  little  salad,  and  fruit;  6  to  8 
ounces  (178  c.c.  to  236  c.c.)  of  wine,  with  4  or  5  ounces  (120  c.c.  to 
148  c.c.)  of  water. 

Some5  cases  of  obesity  are  due  mainly  to  an  excessive  amount  of 
water  in  the  tissues.  In  such  a  case,  Kanke's  diet  is  to  be  recom- 
mended, meat,  280  gm. ;  fat  100  gm. ;  bread,  400  gm.;  the  limitation 
of  the  amount  of  fluid  ingested,  allowing  only  400  c.c.  more  water 
to  be  taken  daily  in  drink  and  food  than  the  daily  amount  of  urine 
secreted.  To  carry  this  out,  the  percentage  of  water  in  different 
forms  of  food  must  be  estimated. 

Von  Noorden's1  dietetic  measures  are  widely  recognized  and  are 
based  on  scientific  principles.  In  every  case  a  general  estimate 
should  precede  the  actual  reduction  cure  in  order  to  determine  the 
patient's  "maintenance  diet.''  Since  the  obese  tissue  does  not  par- 
ticipate in  energy  production  one  must  calculate  by  how  much  the 
weight  of  a  stout  individual  exceeds  that  of  a  normal  person  of  the 
same  height.  The  number  of  calories  essential  are  obtained  by  mul- 
tiplying the  body  weight  by  the  caloric  value  per  kilo. 

The  maintenance  diet  of  an  obese  patient  is  then  the  caloric  value 
per  kilo,  multiplied,  not  by  the  weight  of  the  patient,  but  by  that  of  a 
normal  individual.  Of  course,  there  are  certain  errors  involved, 
but  for  practical  purposes  this  method  suffices. 

Von  Noorden1  recognizes  three  degrees  of  reduction  diet.  If,  for 
example,  the  maintenance  diet  of  an  individual  is  estimated  at  2500 
calories,  the'  three  degrees  of  diet  reduction  would  be:  (1)  four- 
fifths  of  the  demand,  or  2000  calories;  (2)  three-fifths  of  the  de- 
mand, or  1500  calories;  (3)  two-fifths  of  the  demand,  or  1000  to  1500 
calories.  For  Diet  I,  omit  all  visible  fat,  as  butter,  oil,  meat  fat; 
also  prepare  vegetables  and  dishes  made   Prom  flour  with  little  fat. 


REDUCTION    OF   OBESITY  365 

This  measure  would  cut  calories  down  to  2000.  For  Diet  II,  besides 
the  above,  dishes  from  flour,  stewed  fruits,  and  milk,  must  be 
omitted.  These  patients  should  eat  abundant  albuminous  foods,  as 
lean  meat  and  cheese. 

For  Diet  III,  the  following  articles  of  food  should  comprise  the 
diet:  Coffee,  tea,  meat  broth  (fat  skimmed  off)  with  vegetables, 
lean  meat  or  fish,  lean  cheese,  abundant  green  vegetables  and  salads 
with  little  fat  and  oil;  vinegar,  lemon,  pickles,  tomatoes,  celery, 
radishes,  raw  fruit,  with  small  percentage  of  sugar  (apples,  peaches, 
strawberries,  raspberries,  currants,  blueberries,  grape-fruit,  early 
oranges),  coarse  bread  (bran  or  graham)  in  quantities  from  40  to 
70  grams,  potatoes  (in  quantities  of  80  to  150  grams),  mineral 
waters  ad  libitum,  one  to  two  eggs,  skimmed  milk,  and  buttermilk. 

A  diet  of  low  caloric  value  should  be  made  up  from  the  foods 
mentioned. 

In  analyzing  this  dietary  further,  one  should  consider  the  rela- 
tive amounts  of  fats,  carbohydrates  and  proteins,  and  the  question 
of  water  ingestion.  Fats  are  very  much  diminished,  down  to  30 
grams  per  day.  Lower  than  this  one  can  not  go  because  many  of 
the  essential  foods  contain  some  fat.  Carbohydrates  are  high  in 
von  Noorden's  system.  One  hundred  to  one  hundred  twenty  grams 
per  day  should  be  prescribed.  Such  an  amount  can  be  procured 
from  500  gm.  potatoes,  100  gm.  coarse  bread,  or  1000  gm.  apples, 
etc.  The  reason  for  allowing  large  amounts  of  carbohydrate  is  that 
the  body  albumin  is  spared.  Also  carbohydrate  food  occupies  a 
large  volume  and  tends  to  be  filling.  It  is  essential  that  the  pa- 
tient's sense  of  hunger  should  be  satisfied,  otherwise  his  strength 
and  energy  are  diminished. 

An  abundant  amount  of  protein  is  advisable,  this  to  be  obtained 
from  lean  meat,  eggs,  and  cheese.  One  should  begin  with  120  gm. 
of  albumin  and  gradually  increase  to  not  more  than  180  gm. 

The  diet  in  Reduction  III  may  then  be  tabulated  as  follows: 


Minimal 

Maximal 

Albumin 

120  gm., 

490  cal. 

Albumin 

180  gm., 

738  cal. 

Fat 

30  gm., 

280  cal. 

Fat 

30  gm., 

280  cal. 

Carbohydrate 

100  gm., 

410  cal. 

Carbohydrate 

120  gm., 

492  cal. 

1182  cal. 

1510  cal. 

The  question  of  water  ingestion  is  a  much  disputed  one.  Certain 
it  is  that  reduction  of  water  will  reduce  appetite  in  some  cases,  but 
in  many  it  will  not.     Water  restriction  is  advisable  in  circulatory 


366  AFTER-TREATMENT    OF    SUBGICAL   PATIENTS 

disturbances.  In  most  eases,  von  Noorden  permits  free  use  of  fluids 
in  the  form  of  plain  water,  alkaline  waters,  coffee,  tea  and  broths. 

There  is  one  very  essential  point  which  most  "cures"  disregard, 
namely,  that  the  future  mode  of  life  of  the  patient  must  he  con- 
sidered. It  is  useless  to  institute  a  cure  which  the  patient  will  not 
continue  to  follow  and  therefore  once  more  reestablish  his  obesity. 
On  this  account  one  should  adhere  as  closely  as  possible  to  the 
ordinary  mode  of  life  of  each  individual  and  make  restrictions  ac- 
cordingly.   One  must  also  not  fail  to  vary  any  routine  occasionally. 

2.  Mechanical  Treatment. — Mechanical  treatment,  the  purpose  of 
which  is  to  increase  oxidation,  comprises  (1)  exercise.  (2)  massage, 
(3)  hydrotherapy.  (4)  ''passive  ergotherapy." 

1.  Exercise  causes'  direct  destruction  of  the  fatty  deposits  of  the 
body.  In  postoperative  conditions,  of  course,  intensive  exercise  is 
impossible  at  first.  Breathing  exercises  are  generally  permissible. 
Various  trunk  and  hand  movements  may  be  tried,  systematically 
and  frequently.  As  soon  as  the  patient  is  allowed  on  his  feet,  if 
there  are  no  contraindications,  walking  out  of  doors,  climbing,  gym- 
nastics for  trunk  and  limits,  milder  games. — all  are  invaluable  in 
the  successful  treatment.  The  patient's  cardiovascular  system  must 
always  be  considered  in  advising  exercise. 

2.  Massage  may  be  of  value,  particularly  in  reduction  of  local  de- 
posits, as  of  the  abdomen.  A  course  of  deep  massage  with  Swedish 
movements  should  be  tried. 

3.  Hydrotherapeutic7' 8>  9  measures  are  often  of  great  value. 
Sweating  by  means  of  the  steam  or  Turkish  baths,  etc..  may  pro- 
duce marked  loss  of  weight,  but  as  a  matter  of  fact,  the  loss  is 
chiefly  of  water,  which  is  soon  replaced.  Sweating  causes  no  loss  of 
fat.  In  patients  with  circulator}'  disturbances  and  edema,  sweat- 
ing is  recommended.  When  this  is  done  in  conjunction  with  cold 
bathing,  however,  much  may  lie  accomplished.  Following  the 
sweating,  the  patient  takes  a  cold  bath  or  cold  sponge  and  a  cold 
rub.  Exercise  following  this  is  very  effective.  This  method  stim- 
ulates the  circulation  and  respiration  and  causes  destruction  of  fat. 
Milder  measures,  as  cold  rain  douches  or  cold  sitz  baths  during  the 
day,  may  be  undertaken. 

4.  "Passivi  Ergotherapy." — Recently  much  attention  has  been 
drawn  to  "passive  ergotherapy"  or  "electrically  excited  muscular 
work."  This  method,  as  defined  by  Smith/  consists  in  an  applica- 
tion of  the  faradic  current  by  which  the  muscles,  in  groups  or  in 
entirety,    are    thrown    into    rhythmic    contractions,    "without    dis- 


REDUCTION    OF    OBESITY  367 

comfort  or  fatigue  to  the  patient,  without  strain  on  the  heart,  and 
with  beneficial  effect  on  the  muscles  themselves."  The  faradic  cur- 
rent is  provided  by  a  coarse-wound  coil,  capable  of  giving  a  large 
output  at  a  low  voltage.  The  electrodes  are  large  metallic  ones,  the 
supply  to  each  being  controlled  by  rheostats.  The  method10  is  ap- 
plicable particularly  in  those  cases  of  obesity  in  which  muscular 
exercise  is  difficult,  as  in  cases  of  very  extreme  obesity,  of  compli- 
cated heart  affections,  of  foot  or  joint  troubles.  In  cases  of  weak- 
ened abdominal  muscles,  so  often  coexistent  with  obesity,  passive 
ergotherapy  is  especially  indicated.  The  current  is  directed  to  the 
muscles  themselves.  This  method  of  reduction  protects  the  heart 
upon  which  voluntary  muscular  exercise  may  have  a  detrimental 
effect. 

3'.  Medicinal  Treatment. — On  the  whole,  the  many  varied  mineral 
water  cures  give  but  temporary  relief.  They  are  therefore  neither 
satisfactory  nor  successful.  Thyroid  extract  is  probably  the  only 
drug  which  is  effective.  Its  use,  however,  should  be  limited  to  cases 
showing  hypothyroidism.  There  are  some  patients  who  do  not  re- 
spond to  even  strict  dietary  measures  and  vigorous  mechanical  proc- 
esses, also  others  in  whom  fat  is  quickly  regained.  In  them  one 
should  suspect  hypothyroidism  and  a  justified  etiologic  treatment 
may  be  instituted;  i.e.,  feeding  of  thyroid  preparations.  They 
should  not  be  given  in  those  cases  of  obesity  due  to  overfeeding  or 
lack  of  exercise,  because  such  treatment  does  not  aim  at  removal 
of  the  real  cause.  The  thyroid  preparations  should  be  given  along 
with  full  maintenance  diet  and  large  amounts  of  albumin.  It  is  best 
to  start  with  small  amounts  and  slowly  increase  to  three  to  five 
grains  three  times  a  day.  Larger  quantities  will  produce  irrita- 
bility of  the  heart. 

Dr.  Stuart  McGuire  presents  these  instructions  to  patients  who 
are  subject  to  obesity  as  they  leave  the  hospital. 

Your  "wound  requires  no  further  attention. 

An  abdominal  binder  should  be  used,  both  day  and  night.  During  the  day  a 
comfortable  corset  may  be  worn  over  the  binder. 

You  may  safely  walk  at  once.  Start  with  a  short  walk,  the  distance  of  two  or 
three  city  blocks,  and  increase  gradually. 

Go  slowly.  At  first  you  should  be  cautious  even  in  such  matters  as  straining 
at  stool,  getting  in  and  out  of  the  bath  tub,  and  the  like.  Tub  baths  are  not, 
however,  objectionable.  For  three  to  six  months  be  careful  about  getting  on  and 
off  cars,  lifting  weights,  the  use  of  the  sewing  machine,  athletic  sports,  heavy 
manual  work,  etc. 

Drugs  such  as  thyroid  extract,  antifat  cures,  etc.,  should  not  be  employed  ex- 


368  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

cept  under  supervision  of  your  physician.  They  are  capable  of  harm  unless 
properly  controlled. 

The  following  diet  is  adapted  to  a  safe  reduction  in  weight : 

Take  one  pint  of  hot  water  slowly  before  rising  or  while  dressing. 

At  the  usual  breakfast  hour,  take  a  cup  of  tea,  or  coffee,  without  milk  or 
sugar,  a  small  mutton  chop  or  beefsteak,  or  one  egg,  and  one  slice  of  toast. 

At  2  o'clock,  eat  all  you  desire  of  any  one  of  the  following  meats  and  vege- 
tables, the  latter  cooked  without  meat: 

(a)  Well-done  roast  beef,  steak,  mutton,  fowl,   or  raw  oysters. 

(b)  Spinach,  tomatoes,  cabbage,  turnip  tops,  celery,  parsnips,  apples,  rhubarb. 
At  6  o'clock  eat  one  slice  of  well-toasted  bread  and  one  poached  or  soft-boiled 

egg- 

At  bedtime  take  one  pint  of  water. 

Prevent  constipation  by  exercise,  a  regular  habit,  and  mild  laxatives  occasion- 
ally if  necessary. 

Open  air  exercise,  gradually  begun  and  progressively  increased,  and  a  tran- 
quil mind  are  most  important. 

Avoid  carefully  bread,  beans,  peas,  potatoes,  all  sweets  and  pastry,  and  fluids 
with  your  meals. 

Strictly  followed,  this  regime  should  reduce  your  weight  one-half  pound  per 
day.  If  more  is  lost,  let  up  on  the  diet  every  fifth  day,  and  eat  moderately  of 
fruits. 

Full  credit  is  due  Alfred  Goldman  for  having  abstracted  all  the 
literature  to  which  reference  is  made  in  this  chapter. 

BibliogTaphy 

ivon  Noorden:     Disorders  of  Metabolism  and  Nutrition,  i,  viii,  ix. 
sSchweniger:     Sammlung  Med.  Abhandl.,  No.  4. 
sEbstein:     Dio  Heilkunde,  1902,  No.  2. 

*Oertel:     Obesity,  Twentieth  Century  Practice  of  Medicine,  ii. 
5 Anders:     Modern  Medicine,  Osier. 
eGermain :     Del  'obesite. 

^Winternitz :     Therapieder  Gegenu,  1899,  p.  50. 
sSniith:     Practitioner,  1916,  xcvii,  p.  264. 
^Taussig:     The  Medical  Fortnightly,  St.  Louis,  May,  1903. 
icRobinson:     New  York  Med.  Jour.,  1915,  cii,  p.  329. 


CHAPTER  XLV 

ARTIFICIAL  NUTRITION 
By  Willard  Bartlett  and  M.  G.  Peterman,  St.  Louis,  Mo. 

Modern  artificial  feeding*  probably  began  with  Galen  and  Celsus. 
These  men  were  the  first  to  use  rectal  alimentation.  Medicine  has 
made  considerable  advance  since  the  second  century  and  artificial 
nutrition  has  become  more  and  more  important.  The  problem  of 
artificial  nutrition  after  certain  operative  procedures  involves  not 
only  a  question  of  the  protein,  carbohydrate,  and  fat  requirement 
in  the  repair  and  up-building  of  tissues,  but  often  presents  a  more 
serious  and  complicated  phase  in  the  administration  of  the  body 
needs.  The  chapter  on  Dietetics  deals  with  the  proper  foods  after 
various  operative  conditions.  It  is  the  purpose  of  the  authors  to 
here  consider  the  various  difficulties  which  present  themselves  to 
the  surgeon  after  operations  which  make  it  impossible,  either  tem- 
porarily or  permanently  for  the  patient  to  take  food  through  the 
normal  channel. 

It  may  be  well  to  mention  the  normal  food  requirements  of  the 
average  individual,  and  the  lowest  limits  on  which  the  body  can 
carry  on  its  functions  and  processes  without  utilizing  living  tissues. 
The  average  adult  consumes  daily  about  118  gm.  of  protein,  500  gm. 
of  carbohydrate,  and  56  gm.  of  fat,  a  total  of  3055  calories.1  Ex- 
periments have  shown,  however,  that  health  and  strength  may  be 
maintained  on  a  diet  of  20  to  30  gm.  of  protein,  provided  the  neces- 
sary caloric  requirement  is  made  up  with  carbohydrate  and  fat.2 
Atwater  gives  a  standard  diet  for  a  man  at  rest  which  consists  of 
90  gm.  of  proteins  with  carbohydrates  and  fat  to  make  2450  calories. 
In  prolonged  feeding  the  inorganic  salt  and  the  vitamine  require- 
ment must  also  be  taken  into  consideration. 

The  various  methods  by  means  of  which  artificial  nutrition  may  be 
introduced  are:  per  rectum;  through  gastrostomy  or  jejunostomy 
tubes,  by  subcutaneous  injection,  by  intravenous  injection,  by  cu- 
taneous application,  and  by  intraperitoneal  injection.  Of  these 
various  methods  but  two  have  thus  far  proved  satisfactory  for 
practical  application.  Nutrient  enemas  have  been  and  still  are  the 
most  satisfactory  and  practical  solution  of  the  problem  of  artificial 

369 


370  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

feeding.  Gastrostomies  and  jejunostomies  are  becoming  more 
popular  and  more  satisfactory,  the  latter  being  much  easier  to  per- 
form. "We  shall  consider  the  methods  in  their  order  of  practica- 
bility. 

Per  Rectum. — The  old  so-called  nutrient  enema  consisting  of  milk 
and  eggs,  milk  and  bread,  chopped  beef,  minced  pancreas,  or  a 
combination  of  these  foods  still  enjoys  wide  popularity  in  spite 
of  its  worthlessness.  Modern  investigation  has  shown  that  any  of 
these  food  substances  injected  into  the  rectum  serve  little  more 
than  as  irritants  to  the  large  intestine  and  a  source  of  discomfort 
to  the  patient. 

There  is  little  doubt  that  digestion  and  absorption  continue  in 
the  large  intestine.  The  work  of  Erlanger  and  Hewlett  proved  that 
a  dog  may  carry  on  digestion  and  absorption  and  thrive  with  70 
to  83f;  of  his  small  intestine  removed,  provided  that  the  diel  1"' 
carefully  chosen.3  Recent  work,  however,  has  shown  that  absorp- 
tion in  the  colon  is  limited  to  amino  acids  in  their  simplest  forms 
and  to  monosaccharides,  while  the  amount  of  fat  absorbed  may  be 
said  to  be  negligible.  Water  and  alcohol  are  freely  absorbed.  The 
main  function  of  the  large  intestine  may  he  said  to  be  the  excretion 
of  mineral  salts  ami  absorption  of  water.  Of  the  reported  cases  of 
successful  artificial  nutrition  by  the  old  undigested  or  insufficiently 
digested  nutrient  enema  one  must  he  somewhat  skeptical.  Boyd 
and  Robertson1  repcrl  cases  of  seven  young  women  fed  for  seven 
days  entirely  on  enemata  consisting  of  milk  and  eggs,  dextrose, 
and  normal  saline,  the  whole  pancreatized  for  twenty  minutes.  The 
cases  were  reported  as  having  done  well.  Examination  of  the  data, 
however,  shows  thai  the  nitrogen  excreted  in  the  urine  Avas  always 
greater  than  thai  absorbed  by  the  bowel.  Also  the  patients  con- 
tinued to  lose  weight.  Edsall  and  Miller"'  reported  two  cases  of 
actual  absorption  of  enemas  of  peptonized  milk  and  eggs,  bnt  they 
give  figures  which  show  an  average  nitrogen  loss  of  11.8  to  79.9 
gm.  for  the  six  day  period.  Carter'  furnishes  data  on  three  cases 
of  rectal  feeding  in  a  modern  city  hospital  where  nursing  condi- 
tions were  as  good  as  can  be  found.  In  these  cases  the  colon  was 
cleared  daily,  the  injections  were  given  high  up,  and  they  were 
well  retained.  The  24-hour  urine  was  analyzed  and  the  results 
of  the  irrigation  and  all  of  the  stools  were  examined.  The  results 
of  the  enemas  were  an  almost  complete  return  of  the  nutrient  ma- 
terial with  little  or  nothing  absorbed.  The  nitrogen  balance  varied 
from  -.8.81  to  -.24.19  gm..  always  accompanied  by  a  steady  loss  of 
weight.      Goodall7    concludes    thai    the    simple    sugars   and   alcohol 


ARTIFICIAL   NUTRITION"  371 

are  the  only  substances  practical  for  rectal  alimentation.  More 
modern  results  indicate,  however,  that  proper  amino  acids  added  to 
the  enemas  produce  good  results.  The  work  of  Short  and  Bywaters,8 
where  patients  with  gastric  ulcer  were  treated  by  cutting  off  all 
food  by  mouth  and  feeding  by  nutrient  enemas,  shows  that  ni- 
trogenous protein  will  be  absorbed  if  it  is  properly  prepared  to 
make  it  available.  These  patients  were  given  either  normal  saline 
or  milk  peptonized  twenty  minutes  during  the  first  four  days  and 
then  changed  to  milk  pancreatized  for  twenty  four  hours,  to  see  if 
it  would  stop  the  fall  in  the  nitrogen  output.  The  enema  was  pre- 
pared by  boiling  the  milk  in  a  flask,  adding  two  to  four  drams  of 
pancreatized  extract  and  incubating  for  twentty-four  hours,  then 
boiling.  Five  to  eight  ounces  were  given  every  six  hours.  The 
rectum  was  washed  daily,  but  the  washings  were  not  kept,  The 
nitrogen  in  the  urine  was  estimated  by  the  Kjeldahl  method  and  the 
ammonia  nitrogen  by  the  A.  P.  Opie  formalin  method.  These  cases 
showed  that  it  took  twenty-four  hours  for  the  urine  to  show  a  rise 
in  the  nitrogen  output  after  thoroughly  pancreatized  milk  was  fed. 
This  time  is  required  when  mouth  feeding  is  resumed  after  the 
same  conditions  and  is  therefore  the  time  necessary  for  the  body 
to  restore  normal  equilibrium.  The  results  of  the  experiments, 
on  the  whole,  show  a  satisfactory  result  and  justify  the  conclusions 
which  the  author  draws,  i.  e.,  the  daily  output  of  nitrogen  in  the 
patients  fed  with  enemas  of  milk  and  eggs  peptonized  for  30  minutes 
shows  that  almost  no  nitrogenous  material  is  absorbed ;  that  milk, 
pancreatized  for  twenty-four  hours  to  allow  the  formation  of  the 
amino  acids,  furnishes  food  which  is  absorbed  as  demonstrated  by 
the  rise  in  the  nitrogen  output. 

Cornwall9  states  the  modern  views  when  he  sums  up  the  es- 
sential points  in  rectal  feeding.  He  states  that  all  food  should  be 
predigested;  that  the  protein  ration  must  be  considered  in  the 
terms  of  amino  acids  and  of  a  definite  variety  in  particular  propor- 
tion to  favor  nitrogen  economy.  These  amino  acids  are  found  in 
flesh,  milk,  and  eggs.  Flesh  and  eggs  putrefy  and  are  therefore 
not  advisable.  Milk  is  protected  against  putrefaction  by  the  finely 
mixed  lactacidifiable  carbohydrate.  Milk  is  therefore  the  ideal 
food  and  if  properly  prepared  furnishes,  when  supplemented  with 
the  sugars,  a  practical  and  satisfactory  solution  to  the  problem  of 
nutrient  enemas.  Cornwall  believes  that  by  using  fresh  and  un- 
boiled milk  the  vitamines  and  the  enzymes  are  preserved.  The  milk 
should  be  thoroughly  peptonized  and  pancreatized  to  reduce  the 
proteins  completely  to  amino  acids.    The  fat  must  be  skimmed  from 


372  AFTER-TREATMEXT    OF    SURGICAL   PATIEXTS 

the  milk,  for  it  is  not  absorbed  and  putrefies  in  the  intestine.  To 
the  prepared  milk  should  be  added  glucose  in  solution.  The  salts 
contained  in  milk  closely  approximate  the  normal  body  requirements 
though  calcium  and  sodium  are  only  necessary  when  long-continued 
feeding  is  required.  The  solution  prepared  for  the  enema  should 
always  be  alkaline.  This  avoids  irritation  and  stimulates  absorption. 
Also  it  more  nearly  approaches  and  preserves  the  alkalinity  vital  to 
the  proper  functioning  of  the  body  tissues.  To  these  points  may  be 
added  several  precautions  to  be  observed  in  the  administration  of 
the  alimentation.  The  solution  should  not  be  a  chemical  or  me- 
chanical irritant.  It  should  always  be  alkaline  and  it  should  be 
given  to  avoid  irritation.  If  necessary  opium  should  be  added  to 
the  enema  to  allay  inflammation.  An  inflamed  mucosa  will  not 
absorb  properly.  The  rectum  should  always  be  clean.  This  pre- 
vents putrefaction  and  hastens  absorption.  The  enemas  should  be 
given  high  up  and  the  foot  of  the  bed  should  be  raised  on  blocks 
with  the  patient  lying  on  the  right  side.  This  position  should  be 
maintained  for  an  hour  after  injection.  The  amount  of  material 
given  should  be  carefully  measured.  Although  the  enema  will  not 
usually  pass  the  ileocecal  valve,  the  liquid  may  pass  up  into  the 
ileum  and  may  even  reach  the  stomach  presenting  all  the  complica- 
tions of  acute  dilatation.  This  condition  is  rather  uncommon,  but 
it  must  be  borne  in  mind.  In  gastric  conditions,  it  must  not  be 
thought  that  the  rectal  feeding  gives  the  stomach  complete  rest. 
The  injections  are  always  followed  by  a  reflex  or  psychic  secretion. 
This  secretion,  though  not  excessive,  must  not  be  neglected  in  cer- 
tain cases.  The  following  formula?  for  rectal  feeding  have  been 
gathered  from  the  literature  where  the  records  and  data  available 
have  proved  their  merit. 


Dextrose 

50  gm. 

Absolute   alcohol 

50  gm. 

Normal  saline 

1000  gm. 

This  formula  will  furnish  555  calories  of  heat.10  Larger  enema 
in  the  same  proportion  or  enemas  in  greater  concentration  are  not 
advisable.  Larger  amounts  are  not  absorbed  and  greater  concen- 
trations are  too  irritating. 

The  above  formula  may  be  alternated  with  the  following : 

Dextrose  2°-50  g™- 

Alcohol  20-50  gm. 

Pancreatized  milk  or  commercial  amino  acids                 1000  c.c. 

Salt  9  Sm- 


ARTIFICIAL   NUTRITION  373 

Of  this  preparation  250  c.c.  may  be  given  every  4  hours.  It  has 
a  calorie  value  of  420-755  calories. 

Short  and  Bywaters  used  the  following  preparation:8 

Milk  iy2  pt.j  boiled  and  cooled,  to  which  was  added 
Pancreatic  fluid,  %  ounce. 

This  mixture   was   incubated   24  hours,   then   there   was   added, 
Dextrose   (pure),  1%   ounces. 

Four  ounces  of  this  material  may  be  given  every  four  hours,  or 
ten  ounces,  if  retained. 

Cornwall  gives  the  following  excellent  formulae  :9 

Prescription  1. 

Glucose   (pure)  1  oz. 

Strained  juice  of  %  orange. 

Sodium  bicarbonate  30  grs. 

Sodium   chloride  30  grs. 

Water  q.s.   ad.  10    oz. 

This  mixture  is  given  at  6  a.m.,  12  m.,  4  p.m.,  10  p.m.,  and  is  al- 
tered with  5  oz.  of  skimmed  milk  thoroughly  peptonized  and  pan- 
creatized  for  24  hours,  which  is  given  at  8  a.m.,  6  p.m.,  12  p.m. 

With  the  above  schedule  a  colonic  irrigation  of  normal  sodium 
chloride  is  given  every  second  day  and  the  glucose  enema  at  6  a.m. 
following  is  omitted. 

This  prescription  may  be  modified  as  follows : 

The  quantity  of  glucose  may  be  reduced  to  8  oz. 

The  amount  of  glucose  in  the  glucose  enema  may  be  reduced  to 

y2  or  y3  oz. 

The  amount  of  the  glucose  enema  may  be  increased  to  12  oz.  or  to 
16  oz.,  with  or  without  an  increase  in  the  percentage  of  glucose. 

One-fourth  oz.  of  glucose  may  be  added  to  each  milk  enema. 

The  glucose  enemas  may  be  omitted  altogether  with  or  without 
the  substitution  of  a  drink  enema  of  physiologic  saline. 

Five  gr.  of  calcium  chloride  may  be  added  to  each  glucose  enema. 

Cultures  of  acidophilic  bacteria  may  be  added  to  any  of  the 
enemas. 

This  formula  supplies  daily  700  calories,  20  gm.  of  protein,  the 
necessary  salts  and  vitamines,  with  50  oz.  of  water. 

Prescription  2. 

Glucose  1  oz. 
Str.  juice  of  %  orange 

Sodium  bicarbonate  30  gr. 

Sodium   chloride  30  gr. 

Water                             q.s.  ad.     10  oz. 


374  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

This  preparation  is  given  at  6  a.m.,  10  a.m.,  2  p.m.,  6  p.m.,  10  p.m., 

2  A.M. 

The  formula  may  be  modified  as  follows : 

The  same  modifications  may  be  made  of  this  preparation  as  of 
similar  glucose  enemas  in  prescription  1. 

The  sodium  bicarbonate  may  be  increased  to  60  gr. 

The  orange  juice  may  be  omitted. 

Calcium  may  be  added. 

All  of  the  above  preparations  should  be  given  at  100°  F.  and 
slowly.  The  buttocks  should  be  elevated  and  the  patient  should 
lie  on  the  right  side  tor  an  hour  after  the  injection.  For  real 
slow  absorption  the  drip  method  may  be  used  in  administering  the 
fluids. 

Gastrostomy. — Artificial  introduction  of  food  into  the  stomach  for 
practical  purposes  probably  began  when  Kussmaul  first  introduced 
the  stomach  tube  in  1870.  Beaumont  in  1826  fed  St.  Martin  through 
an  artificial  opening  into  the  stomach  and  was  probably  the  pioneer 
in  this  field.11  This  work,  however,  was  more  in  the  nature  of  ex- 
perimentation than  practical  feeding.  Beaumont's  valuable  work 
is  the  foundation  of  our  modern  knowledge  of  the  physiology  of 
digestion.  Although  we  can  not  aceepl  all  of  his  conclusions,  we 
may  gather  much  from  his  results.  At  the  end  of  one  experiment 
he  slates.  "This  experiment  shows  the  necessity  of  mastication,  and 
demonstrates  thai  simple  maceration  at  the  natural  temperature 
will  not  effect  digestion."  However,  in  his  conclusions  he  states 
that.  "The  processes  of  mastication,  insalivation,  and  deglutition, 
in  an  abstract  point  of  view,  do  not  affect  the  digestion  of  food 
or.  in  other  words,  when  the  food  is  introduced  into  the  stomach 
directly  (Fig.  53)  in  a  finely  divided  stale,  without  these  previous 
steps,  il  is  as  readily  and  as  perfectly  digested  as  when  they  have 
been  taken."  The  experiments  did  no1  state  whether  or  not  the 
patient  was  aware  of  the  fad  that  he  was  being  fed.  or  whether 
he  was  hungry  or  satiated.  Both  of  these  factors  have  considerable 
bearing  on  the  digestion  of  f 1  as  modern  investigation  has  shown.12 

The  later  and  more  scientific  work  of  Pavlov  throws  new  light 
on  the  physiology  of  the  stomach.13  The  Russian  scientist  con- 
cludes a  lecture  with.  "I  hope  you  have  been  convinced  of  the 
great  importance  of  the  passage  of  food  through  the  mouth  and 
esophagus,  or.  in  other  words,  and  this,  according  to  our  former 
experiences,  means  much  the  same  thing;  of  the  desire  for  food. 
Without    this    interest,    without    the    assistance    of   appetite,    many 


ARTIFICIAL    NUTRITION 


375 


foods  which  enter  the  stomach  remain  wholly  imsupplied  with  gas- 
tric juice."  This  statement  he  later  limits  by  saying,  "It  is  there- 
fore quite  possible  that  in  the  case  of  some  dogs,  and  at  a  certain 
stage  of  hunger,  the  touching  of  the  mucous  membrane  with  any 


Fig.   S3. — The   introduction  of  liquid   food,    directly   into   the   stomach. 


object  at  hand,  its  mechanical  irritation,  its  distention  by  the  food- 
mass  may  give  the  impulse  which  excites  appetite ;  and  when  the 
appetite  is  awakened  the  juice  flows."  (Fig.  54.)  Matas  had  kept 
a  man  in  good  health  for  fifteen  years  when  we  saw  him,  by  the 
process  here  shown. 


376  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

For  practical  purposes  we  may  assume  that  the  stomach  will  digest 
almost  any  of  the  digestible  foods  which  can  be  introduced  through 
a  tube.  In  other  words,  the  diet  in  feeding  gastrostomy  cases  is 
determined  by  the  condition  of  the  stomach.    The  sooner  after  opera- 


rig.   54. — The  patient  first  ensalivates  his  food  and  then  sends  it  indirectly   into  his  own 
stomach,   which    gives   the   best   possible   results. 

tion  the  patient  is  supplied  with  nutrition  and  fluids,  and  the  sooner 
normal  peristalsis  and  the  digestive  action  set  in,  the  better  the 
prognosis.  Two  excellent  diets  for  gastroenterostomy  or  gastros- 
tomy cases  are  given,  viz.: 


ARTIFICIAL    NUTRITION  377 

Finney's  Diet 

First  day.  First  12  hrs.,  nothing  by  mouth,  nutrient  enemas  every  four 
hours,  alternating  with  continuous  salt  solution  by  the  drip  method.  Second  12 
hrs.,  water  in  4  c.c.  doses  by  mouth.     (By  mouth  or  tube.) 

Second  day. — Increase  water  gradually  up  to  30  c.c.  every  2  hrs. 

Third  day. — Water  30  c.c,  alternating  with  albumin,  4  c.c,  gradually  increase 
quantities  of  each  until, 

Eighth  day. — Any  liquid,  60  c.c  every  2  hrs. 

Ninth  day. — Any  liquid,  90  c.c  every  2  hrs. 

Tenth  day. — Any  liquid,  120  c.c  every  2  hrs.,  discontinue  rectal  feeding. 

Eleventh  day. — One  soft  boiled  egg  in  addition  to  any  liquid. 

Twelfth  day. — Two  soft  boiled  eggs  in  addition  to  any  liquid. 

Thirteenth  day  and  Fourteenth  day. — Soft  diet. 

Fifteenth  day. — Very  restricted  diet,  light. 

Sixteenth  and  Seventeeth  days. — Eestricted  light  diet. 

Eighteenth  day. — Any  digestible  solid  food. 

After  the  eighteenth  day  the  following  diet  list  may  be  gradually  followed  and 
should  be  continued  for  at  least  four  or  five  months:  SOUPS.  Any  light  soup. 
MEATS.  Any  easily  digested  meats  as  brains,  sweetbreads,  beef,  mutton,  lamb, 
poultry  (minced  and  taken  either  broiled  or  boiled).  FISH.  Mainly  the  white 
variety,  mackerel,  bass  as  well  as  oysters  (boiled  or  broiled).  EGGS.  In  any 
form  except  fried.  FATTY  foods,  as  cream,  butter,  olive  oil.  VEGETABLES. 
The  easily  digestible  forms,  best  taken  mashed  or  strained  as  asparagus,  spinach, 
peas,  beans,  potatoes,  carrots,  farinaceous  foods,  any  cereals,  stale  bread. 
DESSERTS.  Any  of  the  light  puddings.  FRUITS,  mainly  stewed.  DRINKS. 
Milks,  buttermilk,  cocoa,  carbonated  mineral  water,  and  plain  water. 

The  following  must  be  avoided:  Rich  soups,  pork,  fried  foods,  veal,  stews, 
hashes,  corned  meats,  twice  cooked  meats,  potted  meat,  liver,  kidney,  duck,  sau- 
sage, crabs,  sardines,  lobsters,  preserved  fish,  salted  or  smoked  fish,  salmon,  cauli- 
flower, radishes,  celery,  cabbage,  cucumbers,  sweet  potatoes,  tomatoes,  beets,  corn, 
salad,  bananas,  melons,  berries,  pineapple,  hot  bread  or  cakes,  nuts,  candies,  pies, 
pastry,  preserves,  cheese,  strong  tea  or  coffee,  alcoholic  stimulants. 

Leube's  Diet,  as  Modified  by  Lockwood 

On  the  second  or  third  day,  2  oz.  hourly  of  artificial  Vichy,  alternating  with  2 
oz.  of  milk  fully  peptonized  for  two  hours.  Each  day  the  milk  is  increased  1-2  oz. 
until  8  oz.  are  taken  every  two  hours  and  the  Vichy  increased  1  oz.  each  day  until 
4  oz.  are  taken  every  two  hours.  Thus  fluids  are  given  every  hour,  either  Vichy, 
or  the  peptonized  milk.  At  the  end  of  a  week  or  ten  days  there  may  be  added 
junket,  fine  cereal,  milk  toast,  and  sometimes  a  soft-boiled  egg.  During  the  third 
week,  creamed  fish  (fresh  or  halibut),  mashed  potatoes,  cream  of  wheat,  or 
hominy,  spaghetti,  puree  of  vegetables,  and  creamed  soups.  Farinaceous  desserts 
such  as  farina,  tapioca,  cornstarch,  blanc  mange,  and  custard.  Avoid  alcoholic 
beverages  for  many  months,  but  after  the  second  week,  weak  tea,  coffee,  or  cocoa, 
or  a  little  milk  and  coffee,  if  it  agrees,  may  be  taken.  The  beverages  should  be 
weak  and  discontinued  if  they  cause  irritation. 

Both  of  the  above  diets  advise  that  no  food  be  given  for  12 
hours  to  24  hours  after  operation.     More  recent  work,  however. 


378  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

indicates  that  if  feeding  is  begun  immediately  after  operation,  the 
results  are  much  better.  When  the  opening  is  completed  the  feed- 
ing is  begun  and  200  to  250  mils  of  whiskey,  coffee,  or  other  stim- 
ulant is  poured  down  the  tube.  The  fluid  should  be  1<>.V  F..  and  may 
be  given  by  the  drip  method.  After  the  operation,  Andresen  ad- 
vises feeding  certain  definite  amounts  at  definite  intervals.  He 
gives  200  mils  of  peptonized  milk,  15  gm.  of  dextrose,  and  8  mils 
of  whiskey  at  2  hr.  intervals.  This  diet  furnishes  2500  calories  and 
may  be  altered  according  to  conditions. 

Jejunostomy. — Much  has  been  written  on  gastrostomy,  no  doubt 
because  it  is  theoretically  the  ideal  procedure  to  supply  food  at  the 
highest  possible  point  in  the  digestive  tube.  In  practice  it  has 
worked  out  so  that  we  have  never  made  a  single  gastrostomy,  but 
many  jejunostomies.  The  stomach  lias  always  been  found  shrunk 
and  retracted,  but  the  intestine  vastly  easier  to  handle.  These  have 
always  been  desolate  subjects,  hence  it  has  seemed  expedient  to 
choose  the  method  which  mosl  easily  solved  the  surgical  problem  in 
hand. 

The  postoperative  feeding  is  exactly  the  same,  no  matter  which 
route  for  the  introduction  of  food  is  chosen. 

Intravenous.— The  intravenous  method  of  feeding  is  attended  with 
danger  and  great  care  should  be  exercised  it  its  use.  For  immediate 
results  intravenous  injections  are  of  considerable  value.  The  two 
formulae  following  are  taken  from  Carter's  Nutrition  and  Clinical 
Dietetics. 

I  )c\t  rose  50  gm. 

Sodium   chloride  '.»  gm. 

Adrenaline   ehloride  (1-1000   sol)    10  gtt. 

Ai|ua  destillata  q.  s.  ad.         1000    c.c. 

Filter  and  boil  and  give  intravenously  b.  i.  d. 

For  children: 

Dextrose  55      gm. 

Potassium  chloride  .2  gm. 

I  lalcium  chloride  .'2  gm. 

Sodium    earbonate  .1  gm. 

Aqua  destillata  q.  s.  ad.         1000      c.c. 

Filter,  boil  and  give  intravenously  b.  i.d. 

The  above  formulae  should  be  given  in  apparatuses  which  may  be 
carefully  regulated  as  to  the  flow.  The  fluid  should  be  given  very 
slowly  to  prevent  excretion  by  the  kidneys. 

The  excellent  work  of  Woodyatt24  throws  new  light  on  the  in- 
travenous injection  of  glucose.  This  work  proves  withoul  doubl 
that  a  man  of  70  kg.  resting  in  bed  may  receive  and  utilize  63  gm. 


ARTIFICIAL    NUTRITION  379 

of  glucose  by  vein  per  hour  without  glueosuria.  This  means  a  caloric 
value  of  6,048  calories !  Thus  we  may  inject  an  enormous  caloric 
diet  which  will  be  readily  utilized  and  give  immediate  results. 
Woodyatt  mentions  two  precautions  to  be  observed  in  the  injection 
of  glucose,  i.e. —  " — too  great  dehydration  on  the  one  hand,  and 
heart  failure  from  imposing  too  much  mechanical  work  on  the  other. 
These  can  both  be  avoided  by  knowing  the  number  of  grams  of 
glucose  which  enter  the  body  hourly,  what  volume  of  water  is 
moved  by  such  a  rate  of  sugar  injection." 

In  using  the  injection  of  glucose  for  artificial  nutrition  the 
Woodyatt  apparatus  is  advisable.  This  description  of  the  mechan- 
ism is  taken  from  the  author's  article  which  appeared  in  the  Journal 
of  the  American  Medical  Association,  December,  1915. 

"The  machine  consists  of  a  glass  syringe  barrel  with  a  metal 
piston  provided  with  a  piston  ring  (record  syringe),  the  barrel 
being  fixed  while  the  piston  is  actuated  by  a  piston  rod  from  an 
eccentric  on  a  power  shaft.  The  latter  is  driven  by  an  electric  motor 
through  a  worm  and  gear  which  reduces  the  speed  of  the  motor 
and  increases  the  power  correspondingly.  On  the  nozzle  of  the 
syringe  there  is  a  two-way  all-metal  valve  of  special  design  which 
is  turned  automatically  by  a  cam  shaft  and  alternately  permits  an 
influx  or  outflow  of  fluid  to  or  from  the  pump  barrel.  The  rate  at 
which  the  machine  delivers  fluid  is  controlled  in  three  ways:  first 
by  the  size  of  the  barrel,  which  is  interchangeable  so  that  any 
capacity  can  be  used  from  .5  c.c.  to  10  c.c;  second  by  a  device  which 
regulates  the  stroke  of  the  piston  to  any  desired  length  from  a 
millimeter  up,  and,  third,  by  a  rheostat  with  Avhich  the  motor 
speed  can  be  controlled  delicately  while  running  so  that  the  pump 
makes  any  desired  strokes  per  minute  between  15  and  60. 

"The  machine  is  intentionally  provided  with  a  surplus  of  power. 
It  is  heavily  built  and  of  a  high  grade  of  workmanship.  It  pumps 
precisely  and  relentlessly  anything  from  water  to  an  80%  glucose 
syrup,  at  any  rate  from  10  c.c.  to  5  liters  hourly,  overcoming  with 
negligible  variations  in  speed  any  obstructions  which  may  occur  in 
the  tubing  or  the  intravenous  cannula  or  needle.  All  parts  which 
come  into  contact  with  the  fluid  to  be  injected  are  detachable  and 
sterilizable." 

Subcutaneous. — There  is  little  to  be  found  in  the  literature  on 
successful  results  in  administering  nutrition  via  the  subcutaneous 
method.  This  is  rather  a  dangerous  procedure  and  should  not  be 
resorted  to  until  the  other  methods  are  unavailable.     Among  the 


380  AFTER-TREATMENT   OF   SURGICAL   PATIENTS 

more  or  less  successful  experiments  may  be  mentioned  the  follow- 
ing: 

Kreng16  in  1876  stated  that  he  successfully  nourished  a  patient  for 
20  days  on  subcutaneous  injections  of  olive  oil,  but  he  gives  no 
figures  or  data  as  to  the  weight  or  strength  of  the  patient  during 
and  after  the  feeding.  Whittaker"  in  1877  quoted  a  case  of  a  man 
nourished  for  6  days  with  subcutaneous  injections  of  milk,  beef 
extract,  and  cod  liver  oil.  In  report,  however,  he  gives  no  data 
as  to  the  body  weight,  the  amount  of  food,  or  the  excretion.  In- 
dividuals may  survive  long  periods  and  show  little  evidence  of 
malnutrition.  Unless  the  nitrogen  output  is  measured,  it  is  im- 
possible to  determine  the  exact  condition  of  the  patient.  Eichornls 
in  1881  published  a  report  of  feeding  cow's  milk,  Sander's  peptone, 
and  egg  albumin.  lie  states  that  egg  albumin  injected  subeu- 
taneously  produces  abscess,  and  thai  cow's  milk  is  only  slowly  ab- 
sorbed, but  that  there  is  no  reaction  from  the  injection  of  20  gm. 
of  peptone.  Eichorn  concludes  that  peptone  may  be  used  to  ad- 
vantage. His  work,  too,  lacks  the  necessary  data  to  determine  its 
worth.  Leube19  in  1895  injected  sugar  subcutaneously  and  deter- 
mined that  if  a  few  c.c.  were  injected  at  a  time  15  to  20  g.m.  might 
be  injected  daily.  lie  used  a  20  per  cent  solution  of  glucose.  This 
method  is  only  an  aid  to  lie  used  in  conjunction  with  other  means. 
Perhaps  with  an  apparatus  similar  to  the  Woodyatt  intravenous 
contrivance  whereby  glucose  could  be  injected  slowly  and  at  a 
definite  rate,  the  subcutaneous  route  may  offer  more  successful  re- 
sults. Barker20  in  1905  stated  that  the  glucose  should  be  in  5  per 
cent  solution  in  normal  saline  and  reported  several  eases  of  arti- 
ficial nutrition  by  this  method.  Henderson  and  Crofutt21  in  the 
same  year  found  that  oil  injected  subcutaneously  was  absorbed  too 
slowly  to  be  of  value  in  nutrition. 

Subcutaneous  feeding  may  be  best  summed  up  with  the  original 
experiments  of  Carter.22  A  set  of  six  experiments  was  carried  out 
on  a  number  of  dogs.  The  animals  were  first  placed  on  the  normal 
laboratory  diet  and  kept  on  this  until  there  was  no  change  in  weight. 
All  excreta  was  saved,  the  dogs  were  weighed  daily,  and  they  were 
carefully  watched  for  clinical  symptoms. 

Experiment  1.  Somatose  and  glucose  were  injected  in  normal 
saline.  The  first  injection  caused  a  severe  reaction  of  toxemia. 
The  dogs  had  a  high  temperature,  marked  trembling,  and  weak- 
ness. Later  the  toxemia  became  less  marked,  but  the  temperature 
rose,  the  weakness   increased,   and   the   urine   showed  hyaline   and 


ARTIFICIAL   NUTRITION  381 

granular  casts,  albumin,  peptones,  and  sugar,  and  a  severe  edemr. 
followed. 

Experiment  2.  The  alkali  albuminate  of  meat  was  injected.  This 
was  followed  by  a  bloody  diarrhea,  vomiting,  renal  irritation,  and 
local  necrosis  at  the  point  of  injection. 

Experiment  3.  Milk  peptone  with  the  cream  removed,  digested 
3  hours  with  the  dried  extract  of  pancreatic  gland  and  dilute  sodium 
carbonate  was  sterilized  by  boiling.  This  preparation  was  fed  to 
a  pregnant  dog.  The  injections  were  followed  by  only  moderate 
symptoms  of  toxemia  but  there  was  a  continual  loss  of  weight.  In 
a  few  days  the  dog  delivered  pups  but  only  one  lived.  The  mother 
was  unable  to  nourish  the  pup  and  both  died  shortly. 

Experiment  4.  The  milk  preparation  in  Exp.  1,  was  fed  to  a 
normal  dog,  and  toxemia  followed. 

Experiment  5.  Skimmed  milk  was  peptonized  1%  hours  and  was 
first  fed  by  mouth  until  the  dog  became  accustomed  to  the  diet. 
Then  the  subcutaneous  feeding  was  begun  and  the  mouth  feeding 
was  gradually  stopped.  Toxemia  followed  shortly  and  death  re- 
sulted in  3  days. 

Experiment  6.  The  same  milk  preparation  was  fed  but  the  in- 
jections were  begun  with  .098  gm.  per  kilo.  This  experiment  was 
followed  by  little  reaction  and  the  results  were  good. 

Carter  summarizes  his  experiments  by  stating  that :  Skimmed 
milk,  peptonized  for  1%  hrs.  may  be  fatal  when  injected  subcu- 
taneously  and  that  hypodermic  injections  of  meat  peptones  and 
alkali  albuminate  are  not  feasible  because  of  their  great  toxicity 
and  the  tendency  to  local  necrosis.  He  feels,  however,  that  meeting  the 
full  nitrogen  requirement  is  possible  by  the  injection  of  skimmed 
milk,  peptonized  1%  hours  and  given  in  gradually  increasing  doses. 
The  great  toxicity  of  hypodermic  injections  of  protein  makes  sub- 
cutaneous feeding  rather  a  questionable  procedure  to  be  resorted  to 
only  in  emergency.  The  use  of  aseptic  serum  or  ascitic  fluid,  up  to 
400  c.c.  daily  is  the  preferable  protein  to  inject  for  maintaining  in 
part,  the  nitrogen  balance.  In  hypodermic  injections  it  must  be 
remembered  that  slow  injection  is  necessary  for  complete  absorption. 
If  the  fluid  is  injected  rapidly  it  may  be,  for  the  most  part,  ex- 
creted by  the  kidneys. 

Intraperitoneal. — This  method  of  artificial  feeding  has  not  been  of 
practical  use.  Few  experiments  are  found  in  the  literature  and 
nothing  of  practical  value  is  reported.  The  injection  of  a  foreign 
substance  into  the  peritoneal  cavity  is  too  serious  an  undertaking  to 


:"J^2  AFTER-TREATMENT    OF    SURGICAL    PATIEXTS 

allow  of  feeding  by  this  method.  Serum  and  glucose  have  been 
introduced  intraperitoneally.  but  the  results  have  not  warranted 
consideration  of  this  method.  There  are  few  eases  where  the  afore- 
mentioned methods  will  not  be  found  feasible  and  their  use  is  far 
less  hazardous. 

Cutaneous  Application. — This  method  of  feeding  by  inunction  is 
applicable  only  to  infant-.  Cod  liver  oil  rubbed  into  the  skin  in  the 
axilla?  and  the  groins  is  absorbed  to  some  extent  but  only  a  small 
part  of  the  required  intake  may  be  supplied  in  this  manner. 

Full  credit  is  due  M.  G.  Peterman  for  having  abstracted  all  the 
literature  To  which  reference  is  made  in  this  chapter. 

Bibliography 

iVoit :     Physiologie  des  Stoffwechsels. 

-siven:     Skandinavische  Archive  fur  Physiol  _ 

•Erlanger  and  Hewlett:     Am.  Jour.  Physiol..  1902. 

•*Boyd  and  Eobertson:     Scottish  Med.  and  Surg.  Jour..  1906. 

sEdsall  and  Miller:     Wisconsin  Med.  .lour.,  1903. 

eCarter:     Arch.  Int.  Med.,  19    - 

TOoodall:     Boston  Med.  and  Surg.  Jour.,  elxx.  No.  2. 

-short  and  Bywaters:     Brit.  Med.  Jour..  June.  1913. 
wall:     Jour.  Am.  Med.  Assn.,  May  18,  1918. 
loCarter:      Nutrition   and   Clinical   Dietetics,   1917.   Philadelphia.  Lea   ^-    Febiger. 
"Beaumont:     Physiology  of  Digestion,  Is  17. 

isHowell:     Textbook  of  Physiology,  1918,  Philadelphia,  W.  B.  Saunders  Co. 
"Pavlov:     Work  of  the  Digestive  Glands,  1902,  Philadelphia.  J.  B.  Lippincott  Co. 
"Einhorn:     Med.  Bee,  New  York.  .Tun./  16,  1917. 
isAndresen:     Ann.  Surg.,  May.  1918. 

-  Ki>ng:  New  York  Med.  Jour..  March,  1876. 
iTWhittaker:  Am.  Jour.  Med.  Sc.,  April.  1877. 
isEichorn:     Wien.  klin.  Wchnschr.,  1881. 

Leube:     Verhandl.  Congress  Innere  Medecine,  Weisbaden,   1895,  xiii. 

-  Barker:     Am.  Med..  1905,  xiv. 

"Henderson  and  Crofutt:      Am.  Jour.  Physiol.,  1905,  xiv. 
^Carter:     Arch..  Int.  Med.,  April,   1905. 

-  Finney:  Am.  Jour.  Med.  Sc,  1915,  el,  No.  4. 
2«Woodyatt,  et  al :     Jour.  Am.  Med.  Assn.,  December,  1915. 


CHAPTER  XL VI 

CARE  OF  THE  BOWELS  AFTER  OPERATION  OTHER  THAN 
GASTROINTESTINAL 

By  Willard  Bartlett,  St,  Louis,  Mo. 

The  subject  of  pseudoileus  has  been  adequately  treated,  it  is 
hoped,  in  the  chapter  on  ileus;  hence  no  attention  will  here  be  paid 
to  distention,  gas  pains,  etc. 

We  must  divide  the  surgical  convalesence  very  distinctly  into 
two  periods  so  far  as  reference  to  this  subject  is  concerned.  The 
earlier  of  these  has  to  do  with  the  time  that  the  patient  is  in  bed  on 
a  restricted  diet,  and  in  other  respects  is  leading  an  abnormal  exist- 
ence. The  second  period  may  be  defined  as  that  which  begins  when 
the  patient  gets  out  of  bed  and  resumes  to  a  certain  extent  the  tenor 
of  his  customary  existence,  though  somewhat  modified  it  may  be 
to  suit  hospital  conditions. 

During  this  early  period  the  care  of  the  bowels  is  not  infrequently 
left  to  the  patient's  own  discretion  in  all  but  the  best  conducted 
hospitals,  strange  as  this  statement  seems.  Only  one  grade  better 
is  the  plan,  which  many  readers  will  recognize  at  a  glance,  of  leav- 
ing the  whole  matter  to  the  judgment  of  a  more  or  less  experienced 
nurse,  and  while  it  can  not  be  said  that  the  care  of  the  bowels  is 
often  one  of  the  vital  factors  in  the  convalescence,  still  it  is  impor- 
tant enough,  especially  if  diarrhea  be  present,  for  the  operator  or  at 
least  his  house  surgeon  to  have  full  control  of  it,  and  surely  no 
cathartic  should  be  given  in  a  hospital  without  an  order  emanating 
from  a  medical  source. 

It  is  impossible  to  formulate  any  general  rule  governing  this  sub- 
ject, and  here,  as  in  many  other  departments  of  postoperative  treat- 
ment, one  must  individualize.  This  is  true  with  reference  not  only 
to  the  individual  needs  of  patients,  but  it  will  be  readily  admitted 
that  various  surgical  procedures  entail  widely  differing  treatments 
of  the  intestinal  canal.  So  it  comes  about  that  the  best  type  of 
hospital  interne  will  await  indications  before  proceeding  in  the  in- 
dividual case.  This  is  particularly  true  of  the  early  convalescent 
period,  since  during  this  time  one  can  readily  imagine  a  state  of 
depletion  existing  in  many  a  patient  which  would  render  any  ex- 

383 


384  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

hausting  procedure,  such  as  vigorous  catharsis  ma}'  be,  highly  inad- 
visable. So  little  food  is  ingested  during  the  few  days  which  suc- 
ceed a  major  surgical  operation  that  the  need  of  catharsis  on  this 
ground  is  customarily  exaggerated,  I  am  sure.  Of  course,  we  will 
presuppose  the  patient  has  been  subjected  to  the  ordinary  prepara- 
tory measures.  On  the  other  hand,  one  can  imagine  the  subject  to 
have  been  brought  to  the  table  in  an  emergency,  and  then  post- 
operative bowel  movement  no  doubt  becomes  more  urgent  than 
would  otherwise  be  the  case,  though  here  again  one  must  not  fail 
to  individualize.  The  procedure  is,  unfortunately,  not  often  thus. 
Every  operator  will  remember  frequently  having  been  waylaid  in 
the  corridor  by  a  solicitous  relative  who  states  that  the  sufferer's 
bowels  have  not  moved  for  so  and  so  many  days,  or  the  nurse  will 
ask  whether  she  may  not,  on  general  principles,  give  a  dose  of 
castor  oil,  or  the  patient,  who  has  no  local  or  general  complaint 
pointing  to  the  bowel,  will  want  to  know  what  our  hospital  rule  is 
with  regard  to  cathartics.  The  line  of  least  resistance  is  for  the 
medical  attendant  to  tell  the  nurse  to  give  the  patient  a  cathartic, 
leaving  the  choice  to  her,  or  if  he  is  not  quite  so  careless,  he  will 
suggest  an  enema  without  any  further  consideration  of  the  in- 
dividual's needs. 

Of  course  there  do  arise  general  evidences  of  the  need  of  a  bowel 
movement.  They  are  not  easy  to  put  into  words,  but  may  be  stated 
in  general  as  abdominal  discomfort,  tenesmus,  lack  of  appetite,  rise 
of  temperature,  and  a  general  ill  feeling  which  the  patient  is  unable 
to  more  accurately  define.  Where  the  symptoms  are  distinctly 
local,  no  matter  what  their  nature,  a  digital  or  even  possibly  a  proc- 
toscopic rectal  examination  is  to  be  made  in  every  instance,  some- 
thing which  under  the  circumstances  is,  I  am  convinced,  rare  out- 
side of  the  leading  hospitals.  One  who  does  this  for  the  first  time 
will  be  surprised  to  note  the  frequency  of  fecal  impaction,  a  strictly 
local  affair,  which  can  be  best  remedied  by  local  mechanical  meas- 
ures, and  for  which  no  doubt  a  cathartic  is  very  frequently  care- 
lessly given. 

In  order  to  establish  the  need  for  bowel  movement,  one  who  is 
inclined  to  individualize  will  be  interested  when  confronted  by  the 
man  who  has  several  watery  stools  a  day  when  he  is  in  perfect 
health,  as  well  as  by  the  woman  who  for  years  has  gone  about  her 
normal  pursuits  with  never  more  than  one  movement  a  week.  That 
the  needs  of  the  two  differ  greatly  goes  without  saying,  and  this 
is  no  less  true  after  a  surgical  operation  than  before.     It  is  com- 


CAEE   OF    THE   BOWELS  385 

nionly  stated,  and  with  a  certain  degree  of  truth  in  many  instances, 
that  a  patient's  bowels  are  not  likely  to  move  while  he  is  in  bed. 
However,  I  have  been  considerably  more  sanguine  about  this  mat- 
ter since  being  recently  called  to  treat  a  patient  who  had  not  been 
off  his  back  for  fifteen  years,  and  who,  according  to  his  own  state- 
ment as  well  as  that  of  his  attendant,  had  not  missed  a  normal  daily 
bowel  movement  in  all  those  fifteen  years.  A  few  experiences  of 
this  sort  makes  one  less  likely  to  indulge  in  generalities,  and  incline 
him  rather  to  the  line  of  individual  reasoning.  Of  course  this  does 
not  mean  that  nearly  every  patient  confined  to  bed  will  go  without 
help  as  far  as  the  bowels  are  concerned.  However,  it  does  indicate 
that  the  needs  of  each  and  every  one  are  entitled  to  a  special  con- 
sideration. To  be  perfectly  fair,  I  will  state  a  circumstance  in 
marked  contrast  to  that  just  related.  The  high  temperature  of  107° 
was  noted  in  a  young  lady  who  did  not  seem  to  be  very  ill.  She 
stated  that  her  bowels  had  not  moved  for  a  week,  and  that  under 
similar  circumstances  she  had  been  affected  in  this  way  on  other 
occasions.  A  cathartic  was  given,  and  we  were  all  astounded,  after 
her  bowels  moved  in  an  hour  or  two,  to  find  that  her  temperature 
had  returned  to  the  normal.  Nothing  further  developed  in  expla- 
nation of  the  phenomenon;  hence  one  is  forced  to  the  conclusion  that 
there  must  have  been  the  relation  of  cause  and  effect  between  con- 
stipation and  fever  on  the  one  hand,  as  well  as  between  cathartic 
and  result  on  the  other  hand. 

One  is  not  to  be  unreasonable  on  this  point  and  urge  that  no  re- 
gard is  due  the  lower  digestive  tract  of  the  patient  confined  to  bed, 
but  on  the  other  hand  there  are  weighty  enough  reasons  for  seeing 
to  it  that  the  bowels  do  move  after  operation  when  occasion  re- 
quires. Xot  only  are  the  indefinite  general  symptoms  above  outlined 
to  be  relieved,  but  it  is  distinctly  a  physician's  duty  to  see  that  a 
difficult  movement  is  made  easy,  for  the  very  same  reason  that  he 
will  endeavor  to  spare  the  patient  a  violent  effort  of  any  other  kind. 
There  is  perhaps  nothing  worse  for  a  convalescent  patient  than  a 
great  increase  of  intraabdominal  tension,  especially  should  this  be 
continued  for  any  length  of  time.  One  has  but  to  keep  in  mind 
the  pain  in  the  wound  which  is  occasioned  in  this  way,  to  say  noth- 
ing of  the  fact  that  cerebral  apoplexy  occurs  frequently  in  elderly 
individuals  at  stool.  Pulmonary  embolism  is  distinctly  favored  by 
any  increase  in  intraabdominal  tension,  provided,  of  course,  that 
there  be  thrombosed  veins  in  any  part  of  the  abdomen  from  which 
a  fragment  can  be  torn  loose.    Local  evidences  of  undue  strain  of 


386  AFTER-TREATMENT   OF    SURGICAL    PATIENTS 

this  particular  kind  consist  in  the  appearance  of  blood  in  the  stool, 
the  formation  of  hemorrhoids,  and  not  infrequently  the  appearance 
of  prolapse  in  varied  degrees.  The  duration  of  these  manifestations 
will  depend  upon  whether  or  not  the  causal  condition  is  transient 
or  permanent. 

Granted,  now.  that  the  need  for  bowel  movement  has  been  estab- 
lished. Ave  take  up  in  general  the  question  of  how  this  shall  be 
brought  about.  As  is  perfectly  Avell  known,  most  cathartics  ex- 
aggerate the  muscular  activity  of  the  entire  intestinal  tract.  On 
the  other  hand,  x-ray  studies  have  demonstrated  that  the  food  is  in 
a  few  bonis  carried  into  the  colon,  much  of  it  into  the  lower  end  of 
that  viscus. — this,  of  course,  in  the  absence  of  mechanical  obstruc- 
tion. Does  it  not,  then,  seem  logical  to  attack  the  lower,  rather 
than  the  upper  end  of  the  bowel  under  such  circumstances?  This 
would  seem  so.  and  for  a  still  further  patent  reason  to  one  who  has 
been  operated  upon  and  who  has  bad  experience  with  a  large  dose 
of  castor  oil  before  really  recovering  from  the  nausea,  depression 
and  pain  attendant  upon  a  major  surgical  procedure.  I  do  not 
know  of  any  way  in  which  one  can  detract  more  from  the  psychic 
and  physical  comfort  of  an  individual,  sick  or  well,  than  by  giving 
him  a  large  dose  of  the  nauseating  oil.  which  is  so  universally  em- 
ployed under  circumstances  now  discussed.  Hence,  are  we  not  at 
least  justified  in  seriously  considering  the  matter,  especially  in  view 
of  the  x-ray  knowledge  referred  to  above? 

There  are  prophylactic  measures  which  in  many  individuals  with 
special  predilections  render  the  use  of  any  remedial  measures  un- 
necessary. There  are  those  in  whom  a  cup  of  coffee  or  a  cigar  will 
invariably  cause  a  movement  of  the  bowels  soon  after  they  are 
enjoyed.  Others  find  that  they  become  constipated  only  when  de- 
prived of  beer  or  some  of  the  other  malted  drinks,  while  the  em- 
ployment of  fruit  juices  is  universally  valued.  One  can  hardly 
think  of  a  pal  ienl  who  is  given  anything  at  all  in  the  mouth  who  can 
not  tolerate  the  three  classes  of  fluid  just  mentioned. 

Suppose,  now.  that  prophylactic  measures  have  not  availed,  may 
we  not,  before  attacking  the  intestinal  tract  directly,  with  reason 
have  recourse  to  the  various  nonmedical  procedures  which  under  the 
conditions  of  normal  life  are  of  value  in  accentuating  the  intestinal 
functioning  ability?  I  refer  here  to  massage  of  the  abdomen,  di- 
rected particularly  to  the  colon  and  applied,  of  course,  in  the  line  of 
peristalsis.  This  can  be  quite  conveniently  done  by  the  patient 
himself,  if  not  too  ill  and  provided  there  is  not  a  wound  of  the  ah- 


CARE    OF    THE    BOWELS  387 

dominal  wall,  by  running  a  heavy  ball  about  over  the  anterior  ab- 
dominal wall  while  lying  on  the  back.  Many  individuals  are  not 
hindered  by  reason  of  their  malady  from  going  farther  than  this 
and  indulging  in  quite  a  variety  of  light  gymnastics  while  in  the 
recumbent  or  semiprone  position. 

Suppose  that  none  of  the  measures  detailed  up  to  this  point  have 
been  of  any  avail  and  there  are  cogent  reasons  why  the  bowels 
should  be  caused  to  move.  Knowing  that  practically  all  of  the 
food  has  reached  the  colon,  I  have  not  in  recent  years  used  a  general 
cathartic,  unless  for  some  very  especial  reason  which  lack  of  space 
here  forbids,  but  have  resorted  uniformly  to  enemas,  and  must  say 
that  the  results  have  in  general  been  much  more  satisfactory  than 
was  the  case  in  my  earlier  experience  of  another  kind.  But  before 
taking  up  the  various  forms  of  enema  in  detail,  we  must  proceed  to 
disabuse  ourselves  of  the  idea  that  there  is  any  difference  between 
a  low  and  a  high  enema.  The  painstaking  nurse  will  ask,  as  soon 
as  an  enema  is  ordered,  whether  or  not  the  operator  wishes  it  given 
high  or  low.  Xo  such  distinction,  however,  can  be  made  at  the 
present  date  by  those  who  are  familiar  with  Soper 's  x-ray  work  now 
universally  accepted  which  shows  that  a  tube  passed  into  the  rec- 
tum merely  curls  up  if  any  attempt  is  made  to  introduce  a  length 
of  it  greater  than  that  of  the  ampula.  There  are  fluid  substances 
without  number  which  may  be  employed  in  the  form  of  an  enema. 
It  has  been  the  writer's  practice  in  recent  years,  at  the  suggestion  of 
Dr.  Soper  of  St.  Louis,  to  use  in  an  adult  3  ounces  of  a  saturated 
solution  of  magnesium  sulphate,  because  this  is  the  one  chemical 
substance  harmless  in  nature  which  relaxes  the  musculature  of  the 
sigmoid  and  thus  most  readily  lets  the  intestinal  contents  out. 
Soper  believes  that  contracture  in  this  limited  portion  is  the  prin- 
cipal feature  which  we  have  to  combat  in  postoperative  lower  in- 
testinal spasticity.  Some  patients  are  quite  readily  affected  by  mere 
injection  of  a  moderate  amount  of  warm  water,  while  in  others 
soap  suds  very  readily  produce  the  same  results.  Often  a  few 
ounces  of  some  cheap  oil,  like  cottonseed  oil,  is  very  pleasant  and 
effectual,  and  I  have  often  found  that  a  teaspoonful  of  alum  dis- 
solved in  a  pint  of  water  will  bring  about  very  marked  peristalsis, 
although  it  is  quite  probable  that  this  may  seriously  damage  the 
mucous  membrane  of  the  bowel.  Hence,  I  have  not  used  it  in  recent 
years.  Where  there  is  any  objection  to  a  large  quantity  of  fluid,  it 
is  my  practice  to  make  use  of  an  ounce  or  even  two  ounces  of  un- 
diluted glycerine.  This  is  almost  sure  to  start  peristalsis,  although 
this  has  sometimes  been  exaggerated  and  rather  painful  in  nature. 


388  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

Of  course,  an  enema  of  whatever  nature  is  most  transient  in  its 
effect.  Hence  it  may  often  be  well  to  accompany  its  use  by  the  ad- 
ministration of  simple  mineral  oil,  which,  by  lubricating  the  lining 
of  the  bowel  (this  being  nonabsorbable),  tends  to  maintain  in- 
testinal motor  function  after  the  effect  of  the  enema  has  worn  off. 
Patients  vary  greatly  in  the  effect  of  mineral  oil.  One  may  begin 
with  a  half  ounce  administered  four  times  a  day.  and  decrease  or 
increase  as  the  individual  need  indicates.  I  have  seen  many  pa- 
tients in  whom  four  ounces  a  day  were  required,  and  others  who 
could  get  along  with  half  an  ounce  or  an  ounce  equally  well. 

Certain  cautions  may  be  well  observed  by  the  individual  who  has 
never  had  experience  with  mineral  oil.  It  is  a  most  elusive  fluid 
and  can  not  be  very  accurately  controlled  by  every  one.  It  is  not 
wise  to  pass  gas  with  impunity  after  taking  it,  unless  one  happens 
to  be  so  situated  that  a  flood  of  oil  does  not  matter  particularly. 
Many  a  patienl  has  thought  flatus  to  be  escaping  and  later  found 
his  clothing  saturated  with  oil.  or  discovered  that  he  was  actually 
sitting  or  lying  in  a  pool  of  it.  It  awakens  no  peristalsis,  and  in 
consequence  gives  no  warning  of  its  impending  escape. 

Mineral  oil  is  most  heartily  and  unreservedly  recommended  by 
me.  It  is  the  only  substance  of  medicinal  or  semimedicinal  nature 
which  I  give  by  mouth  as  routine  as  an  aid  to  intestinal  motor 
function.  I  have  not  seen  any  difficulty  where  properly  used,  al- 
though  I  am  willing  to  admit  that  some  others  consider  it  to  pos- 
sess  only  a  moderate  value. 

So  much  for  the  early  period  of  a  patient's  convalescence,  when 
he  is  probably  in  the  recumbent  position  and  relatively  quiet  in 
bed.  If  the  bowels  are  to  move  at  all.  we  will  have  had  in  this 
period  io  resorl  in  many  instances  to  some  artificial  aid.  But  let 
us  now  suppose  the  individual  to  be  up.  and  the  second  period  of 
his  recovery  to  be  commenced. 

It  seems  now  nothing  less  than  a  mistake,  to  put  it  mildly,  for 
the  surgeon  to  indulge  in  a  regime  of  cathartics  which  may  lay 
the  foundation  for  future  chronic  constipation.  The  upright  posi- 
tion, especially  at  stool,  will  now  be  of  inestimable  help  to  the 
patient.  Furthermore,  he  should  be  encouraged  to  resume  the 
habit  of  a  lifetime  with  reference  to  going  to  siool  at  a  certain 
hour,  and  as  a  matter  of  course  the  character  and  quantity  of  food 
most  calculated  to  favor  normal  bowel  activity  can  now  be  better 
indulged  in  than  A\as  the  case  when  in  bed.  As  he  begins  lo  ex- 
ercise, lie  will   also  find  without   perhaps  recognizing  it.  that  the 


CARE    OF    THE    BOWELS  389 

use  of  voluntary  muscle  tissue  exerts  a  directly  stimulating  in- 
fluence upon  the  unstriped  musculature  of  the  intestinal  tract. 

Diarrhea. — As  has  been  shown  in  preceding  paragraphs,  consti- 
pation may  play  a  subordinate  role  in  the  convalescence  of  a 
surgical  patient.  On  the  other  hand,  diarrhea  may  be  the  leading 
symptom  of  some  pathologic  condition  which  terminates  fatally. 
Hence  the  extreme  importance  of  considering  this  phase  of  the  sub- 
ject along  with  the  other.  It  is  wholly  illogical  to  talk  about  treat- 
ing diarrhea  when  it  appears  as  a  postoperative  manifestation. 
One  must  diagnose  the  cause,  a  matter  frequently  as  difficult  as  the 
treatment  is  easy,  provided  accurate  indications  can  once  be  es- 
tablished. There  are  here  so  many  possibilities,  as  stated  by  the 
gastroenterologists,  that  the  natural  limitations  of  such  a  chapter 
forbid  us  even  mentioning  all  of  them.  AYe  will,  however,  take  up 
in  some  detail  the  four  varieties  of  diarrhea  which  are  most  fre- 
quently observed  after  a  surgical  operation. 

Nervous. — Nervous  diarrhea  may  appear  after  an  operation  as 
well  as  before  it  in  the  neurotic  type  of  individual,  who  will  admit 
having  been  subject  to  it.  The  nervous  upset  caused  by  the  opera- 
tive procedure,  as  veil  as  the  circumstances  antedating  and  follow- 
ing it,  are  surely  enough  to  bring  on  one  of  these  explosions  so 
characteristic  of  a  certain  type  of  individual.  The  remedy  is  the 
same  as  that  employed  at  other  times.  It  consists  first  of  all  in 
an  exercise  of  will  power  and  self-control  on  the  part  of  the  in- 
dividual, aided  by  the  use  of  sedatives  and  more  liberal  feeding 
than  would  be  employed  in  patients  of  any  other  type  suffering 
from  hyperperistalsis. 

Fermentive. — Fermentive  diarrhea  is  not  common  among  patients 
who  are  carefully  fed  as  a  part  of  the  postoperative  convalescence. 
However,  when  it  does  occur,  it  should  not  be  difficult  to  diagnose, 
and  is  best  treated  by  large,  warm  enemas  given  slowly  to  the 
patient  in  such  a  position  that  the  water  may  find  its  way  up  into 
the  colon  and  wash  out  any  decomposing  material  which  has  not 
already  been  spontaneously  ejected.  If  the  paroxysms  of  pain  be 
very  violent  and  the  circumstances  of  the  case  permit,  a  long-con- 
tinued, warm,  relaxing  tub  bath  is  of  great  value.  Opium  sup- 
positories of  1,  2,  or  3  grains  may  be  needed  to  secure  rest  and 
comfort.  Such  an  upset  is  to  be  followed  by  starvation  within  the 
limits  of  such  a  patient  to  endure,  and  when  feeding  is  recommenced 
the  carbohydrates  should  be  given  distinct  preference,  since  they, 
as  a  matter  of  course,  do  not  decompose  with  the  same  virulent  ef- 
fect as  do  the  albuminous  substances. 


390  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

Stercoral. — Stercoral  diarrhea  from  the  mechanical  irritation  of 
the  colonic  mucosa  is  dependent  upon  the  presence  of  hardened 
feces,  eoproliths,  or  foreign  bodies.  The  diagnosis  is  here  made 
by  digital  proctoscopic  or  x-ray  examination,  and  the  remedy  con- 
sists, as  a  matter  of  course,  in  the  removal  of  the  offending  sub- 
stance. This  in  one  instance  has  necessitated,  in  my  own  hands,  the 
opening  of  the  sigmoid  after  laparotomy,  and  the  removal  of  an 
enormous  fecal  stone.  In  another  I  was  obliged  to  correct  the  posi- 
tion of  a  heavy  uterus  which  dropped  back  upon  the  rectum  and 
rapidly  reproduced  the  same  condition  repeatedly  in  that  viscus. 
It  never  recurred  after  the  uterus  was  definitely  out  of  the  way. 

Septic. — Septic  diarrhea  is  a  distressing  symptom  of  a  grave 
surgical  complication.  It  appears  in  such  a  variety  of  surgical  con- 
ditions and  is  of  such  comparative  frequency  as  to  deserve  much 
more  extended  mention  than  is  here  possible".  It  will  usually  be 
recognized  by  the  fact  that  it  accompanies  other  symptoms  of  a 
septic  nature,  and  will  of  course  be  treated  ao1  only  symptomatically 
by  the  use  of  opium  derivatives  to  the  extent  needed  for  its  con- 
trol, but  the  original  focus,  if  it  can  be  discovered,  must  of  course 
not  be  neglected.  For  the  direct  control  of  septic  diarrhea  I  have 
been  in  the  habit  of  using  1  or  sometimes  2  drams  of  paregoric 
immediately  following  every  bowel  movemenl  in  excess  of  one  in 
twenty-four  hours.  Where  this  has  been  objectionable  to  the  pa- 
tient. I  have  used  suppositories  containing  1  or  2  grains  of  pow- 
dered opium  immediately  after  every  movement  in  excess  of  one  in 
twenty-four  hours.  It  does  not  seem  reasonable  to  lay  down  any 
oilier  tixed  rule  for  the  administration  of  opium  products  than  the 
one  just  referred  to.  since  the  frequency  of  the  bowel  movements 
varies  so  greatly  in  the  different  individuals  that  no  other  procedure 
has  been    found    to    suit    the    requirements    of   all    cases. 

Dr.  Stuart  McGuire  presents  these  instruct  ions  to  every  patient 
suffering  from  constipation  when  lie  leaves  the  hospital: 


In  general  the  diet  should  be  coarse  and  bulky,  containing  especially  the  fibrous 
parts  of  \  egetables. 

On  arising  drink  cue  in-  two  glasses  of  hot  or  cold  water. 

Breakfast:  Fruit,  raw  or  cooked,  except  bananas;  oatmeal;  cream;  corn 
bread,  Graham  bread,  or  bran  biscuits;  plenty  of  butter;  eggs,  except  hard  boiled; 
molasses  or  honey;  coffee.  Milk  affects  individuals  differently;  your  own  ex- 
perience must  guide  you  in  the  use  of  tliis  article. 

in  a.m.,  drink   two   glasses   of   water. 


CARE   OF    THE   BOWELS  391 

Dinner:  Soup;  fish,  oysters;  meats;  chicken  or  turkey;  any  vegetables,  but 
especially  coarse  vegetables,  such  as  string  beans,  spinach,  cauliflower,  celery, 
lettuce,  cucumbers,  tomatoes,  asparagus,  salads  with  oil  dressings;  corn  bread 
or  Graham  bread;  butter,  fruits;  and  desserts  with  or  without  cream. 

4  p.  M.}  drink  two  glasses  of  water. 

Supper:  Breads  of  the  kind  indicated;  butter;  chicken;  oysters;  fish;  eggs; 
molasses  or  honey;  vegetable  salads,  desserts  with  or  without  cream;  coffee. 

On  retiring,  eat  dried  figs,  prunes  or  dates  and  drink  one  glass  of  water. 

II.  EXERCISE 

A  moderate  amount  of  out-door  exercise  should  be  regularly  taken,  but  not 
carried  to  the  extent  of  profuse  perspiration. 

III.    LAXATIVES 

Consult  your  doctor.  Xo  one  laxative  will  prove  efficient  indefinitely.  All  lose 
their  effect  and  have  to  be  changed.  When  it  is  necessary  to  use  any,  the  best  are 
compound  licorice  powder,  eascara,  senna,  and  mineral  oil.  Glycerin  suppositories 
and  soap  suds  enemas  also  have  their  place. 

IV.    HABIT 

It  is  far  better  to  regulate  the  bowels  by  food,  water  and  exercise  than  with 
medicine.  But  it  is  better  to  use  laxatives  or  enemas  than  to  fall  into  the  habit 
of  constipation.  Have  a  regular  time  to  go  to  the  closet,  and  acquire  the  habit 
of  having  an  action  at  this  time.  The  habit  is  not  formed  quickly;  it  may  tak< 
months.     But  once  formed,  it  will  greatly  improve  your  health. 


CHAPTER  XL VII 

TREATMENT   OF  POSTOPERATIVE  RETENTION   OF  URINE 

AND  CYSTITIS 

By  John  R.  Caulk  and  Harry  (i.  Greditzer,  St.  Louis.  Mo. 

Retention  of  urine,  following  surgical  operations,  occurs  with  a 
variable  frequency,  depending  in  a  measure  upon  the  nature  and 
site  of  the  operation,  the  anesthetic  used,  the  temperament  of  the 
individual  and  coexisting  pathologic  conditions  other  than  those  to 
which  the  surgery  was  directed.  Though  it  is  not  a  common  post- 
operative attendanl  to  the  genera]  run  of  surgical  cases,  it  happens 
frequently  enough  to  promote  a  thorough  understanding  of  its 
cause,  and  particularly  of  its  treatment,  since  if  improperly  handled 
such  serious  consequences  may  ensue. 

Postoperative  retention  occurs  more  frequently  after  rectal,  perineal 
and  gynecologic  surgery.  It  lias  been  shown  that  catheterization 
is  necessary  in  from  4  to  L8  per  cenl  of  the  cases  following  labor, 
and  as  high  as  23  to  *-2.~>  per  cent  following  major  gynecologic  surgery. 
The  percentage  is  made  high  by  the  interposition  operation  for 
prolapse  and  extensive  operations  for  cancer  of  the  uterus.  The 
large  majority  of  hemorrhoid  operations  require  catheterization. 
The  more  frequenl  operations  in  general  surgery,  such  as  gall  blad- 
der, appendix,  and  hernia  operations  are  attended  usually  with  a 
very  small  percentage  of  postoperative  retentions,  such  retentions 
often  being  due  to  a  complicating  stricture,  prostate  or  dormanl 
tabes.  A  considerable  number  of  individuals  have  what  might  be 
termed  temporary  retention,  these  usually  void  spontaneously  and 
do  not  require  catheterization.  Taussig  showed  thai  in  the  normal 
postoperative  cases  following  gynecologic  operations  spontaneous 
urination  occurred  on  an  average  of  twelve  hours.  However,  quite 
a  number  of  the  patients  went  from  16  to  33  hours. 

Effects  of  Anesthesia. — It  has  been  pretty  definitely  established 
thai  patients  operated  on  under  local  or  spinal  anesthesia  empty 
their  bladders  a1  a  shorter  interval  and  are  less  apt  to  have  re- 
tention than  patients  who  have  been  subjected  to  a  profound  general 
narcosis.  Furthermore,  the  length  and  depth  of  the  anesthesia 
seems  to  be  a  factor.     It  has  also  been  observed  that   patients  who 


RETENTION    OF    URINE    AND    CYSTITIS  393 

have  required  large  doses  of  morphia  and  sedatives  are  somewhat 
more  prone  to  retentions.  Neurotic  individuals  are  more  prone  to 
postoperative  retentions  than  are  the  phlegmatic  ones.  The  cause 
of  the  retentions  is  usually  put  down  as  a  reflex,  and  often  this  is 
the  case,  yet  there  are  many  patients  who  suffer  postoperative  reten- 
tion who  are  included  in  this  category,  who  in  reality  have  an  ex- 
plosion of  some  organic  central  nervous  system  disease,  or  me- 
chanical obstruction  at  the  neck  of  the  bladder.  Such  cases,  if  not 
transitory,  should  be  cystoscopically  investigated  for  such  complica- 
tions. 

Treatment. — The  average  patient  will  void  in  from  8  to  12  hours 
after  operation.  Should  they  not  void  at  the  end  of  12  hours, 
measures  must  be  instituted  for  the  relief  of  retention,  especially 
if  the  patient  shows  symptoms  of  a  full  bladder,  either  subjec- 
tively or  by  objective  findings,  namely,  the  bladder  dullness  above 
the  pubis.  Should  the  patient  be  comfortable  and  show  no  signs 
of  retention,  he  may  be  given  a  longer  period.  In  the  latter  case 
he  may  be  allowed  to  go  either  until  he  has  a  desire  to  urinate  and 
can  not  or  until  the  bladder  seems  distended.  They  must  not  be  al- 
lowed to  go  so  long  as  to  produce  marked  overdistension  of  the 
bladder,  with  deleterious  effects  on  its  wall,  or  suppression  of  renal 
function.  Should  a  patient  begin  to  void  in  small  amounts  and 
continue  to  do  so,  one  should  be  alert  to  the  fact  that  a  full  bladder 
is  frequently  behind  such  a  performance. 

The  methods  of  treating  postoperative  retention  of  urine  are 
numerous.  In  the  transitory  and  evanescent  type,  most  any  one  of 
the  simple  measures  will  usually  suffice,  whereas  in  the  protracted 
retentions  a  catheter  will  usually  be  required.  Simple  measures 
which  are  most  currently  utilized,  are  the  employment  of  hot  appli- 
cations, such  as  hot  water  bags,  hot  stupes  to  the  suprapubic  region, 
hot  enemas,  and  turpentine  enemas  about  a  dram  to  a  quart ;  chang- 
ing the  patient's  position,  such  as  propping  him  up  in  bed,  and 
even  if  the  case  permits,  allowing  him  to  stand.  This  latter  meas- 
ure when  permissible,  will  often  suffice  to  relieve  a  stubborn  re- 
tention. Massage  of  the  suprapubic  region,  as  advocated  by  some 
is  not  very  successful  and  often  contraindicated.  Pituitrin  has 
been  used  in  recent  years  with  varying  success.  Ebeler  found 
it  extremely  effective,  as  did  Jaschke,  but  other  observers  have 
met  with  considerable  failure.  The  introduction  of  drugs  or  air 
has  been  advocated  by  some.  Braasch  in  1903  proposed  introduc- 
tion of  20  per  cent  boro-glycerin  with  the  hopes  of  stimulating 
bladder  contractions.     Waldstein  used  soap  glycerin  bougies,  and 


394  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

Taussig  proposed  the  intravesical  insertion  of  air.  Glycerin  and 
its  derivatives  have  been  effective  in  numerous  cases;  but  as 
they  are  irritants,  they  are  liable  to  harm  the  already  indis- 
posed bladder  mucosa  and  lend  to  cystitis.  I  can  see  no  excuse 
for  any  of  these  methods  if  a  catheterization  can  be  properly  done. 
Should  these  measures  prove  ineffective,  catheterization  is  the  next 
resort,  and  here  a  word  of  warning  nerds  to  be  issued.  Under  such 
circumstances  catheterization  must  be  done  extremely  carefully  be- 
cause the  soil  is  fertile  for  bacterial  growth.  Since  there  is  retention 
and  usually  bladder  wall  trauma  with  interference  to  the  circula- 
tory and  nervous  mechanism,  catheterization  should  be  executed 
tinder  the  strictest  asepsis,  as  infection  is  likely  to  occur.  When 
properly  done,  such  an  infection  should  be  extremely  rare. 

Catheterization  of  the  Male. — Catheterization  of  the  male  from  a 
urological  standpoint  is  seldom  properly  done  by  the  average  in- 
terne in  the  hospital.  Great  care  is  taken  in  the  scrubbing  of  the 
hands,  the  wearing  of  gloves,  and  the  adornment  of  the  patient  with 
sterile  towels,  and  equal  rare  is  taken  in  the  sterilization  of  the 
catheter,  but  the  more  important,  and  indeed  the  one  important 
feature  of  catheterization  passes  neglected,  namely,  the  thorough 
cleansing  of  the  meatus  and  anterior  urethra  by  swabbing  and 
lavage  to  eliminate  the  bacterial  flora  from  this  region,  which 
though  not  pathologic  in  their  normal  habitat,  may  be  extremely 
so  when  put  into  the  deep  urethra  and  bladder.  This  one  point 
of  cleansing  the  anterior  urethra  should  be  more  thoroughly  taught. 
The  choice  of  catheter  depends  in  a  greal  measure  on  the  individual 
operator.  As  a  general  rule  T  should  say  thai  a  woven  silk  gum 
coude  catheter  is  far  preferable  to  any  other  instrument.  It  is 
usually  easier  to  pass,  and  gentleness  is  the  keynote  in  catheteriza- 
tion. It  is  certainly  less  liable  to  become  contaminated  during 
manipulation  than  a  soft  rubber  catheter,  and  the  silver  catheter 
is  seldom  the  instrument  for  a  novice  who  usually  has  to  do  the 
catheterization.  In  passing  a  catheter  the  inexperienced  often 
becomes  alarmed  at  the  normal  spastic  contraction  of  the  ex- 
ternal sphincter.  "When  one  readies  this  region  with  the  tip  of  the 
catheter,  firm  pressure  should  be  made  and  not  a  to  and  fro  fishing 
motion  as  is  so  frequently  done.  The  spasmodic  contraction  of 
the  sphincter  will  shortly  be  broken  by  firm  pressure.  II  is  ex- 
tremely essential  not  to  intlict  trauma,  as  this  is  the  one  im- 
portant factor  in  the  production  of  infection.  Should  the  retention 
be  due  to  a  latent  stricture,  as  is  very  often  the  case,  urination  may 


RETENTION    OF    URINE    AND    CYSTITIS  395 

be  produced  by  moderate  dilatation  with  nlifornis  and  followers, 
or  soft  woven  bougies.  Stricture  is  occasionally  mistaken  for  spas- 
modic contracture  of  the  external  sphincter  or  obstruction  at  the 
neck,  and  unnecessary  trauma  made  by  repeated  attempts  at  the 
passage  of  the  catheter.  This  mistake  should  not  be  made  if  one 
will  gauge  the  distance  from  the  meatus,  as  most  of  the  impas- 
sable strictures  that  offer  such  confusion  are  located  at  the  bulbo- 
membranous  junction  well  in  front  of  the  bladder  neck,  and  usually 
at  a  distance  of  about  six  inches.  Should  the  retention  be  due  to  a 
prostatic  hypertrophy  which  has  suddenly  become  engorged  fol- 
lowing operation,  a  woven  silk  gum  coude  catheter  is  the  in- 
strument of  choice.  If  this  will  not  pass,  one  will  usually  succeed 
with  either  a  bicoude  or  silver  prostatic  catheter. 

In  the  female  catheterization  is  more  simple,  and  should  be  at- 
tended with  far  less  trauma.  As  females  are  usually  catheterized 
by  the  nurse,  every  hospital  should  give  thorough  instructions  in 
the  routine  catheterization  to  the  nurses.  Here  again  it  is  extremely 
important  to  thoroughly  cleanse  the  meatus  and  the  surrounding 
lips.  The  choice  of  catheter  lies  between  the  female  silver  catheter 
with  a  rubber  connecting  piece,  and  a  woven  catheter.  Glass  cathe- 
ters which  are  so  frequently  used  are  extremely  dangerous.  I  have 
seen  within  the  last  few  years  quite  a  number  of  instances  of  glass 
catheters  having  been  broken  in  the  bladder.  A  soft  rubber  catheter 
is  more  difficult  to  pass,  and  it  is  extremely  difficult  to  prevent  con- 
tamination of  its  distal  end.  Here  again  gentleness  is  paramount. 
After  catheterizing  the  patient,  whether  male  or  female,  the  blad- 
der should  be  thoroughly  washed  with  an  antiseptic  solution,  and 
a  small  amount  of  the  solution  allowed  to  remain  in  the  bladder ;  or 
it  should  be  instilled  with  25  per  cent  argyrol,  or  1  per  cent  silver 
nitrate.  This  administration  of  an  antiseptic  we  believe  is  ex- 
tremely important  and  is  almost  an  insurance  against  infection  if 
the  rest  of  the  procedure  is  properly  executed.  In  a  urological 
office  or  clinic,  patients  may  be  catheterized  for  weeks  or  months 
without  the  slightest  sign  of  infection. 

Very  frequently  one  catheterization  is  all  that  the  average  post- 
operative case  will  require.  There  are  some,  however,  who  demand 
repeated  catheterization  before  normal  urination  is  established.  In 
such  instances  nitrate  of  silver  may  provoke  evacuation.  Should 
retention  be  at  all  protracted,  some  mechanical  or  neurological  ob- 
struction must  be  looked  for,  and  this  corrected  by  proper  measures. 
In  case  catheterization  is  impossible,  and  this  should  be  extremely 


396  AFTER-TREATAIEXT    OF    SURGICAL   PATIENTS 

rare,  suprapubic  puncture  may  be  done.  Suprapubic  puncture  is 
clone  much  more  frequently  than  is  necessary.  Even  in  cases  of 
retention  from  pronounced  grades  of  prostatic  obstruction  there 
is  not  one  case  in  a  hundred  that  can  not  be  catheterized.  As  a 
matter  of  fact  I  have  never  seen  a  case  that  required  suprapubic 
puncture  or  cystotomy  unless  it  were  for  ruptured  urethra  or  im- 
passable  stricture  and.  of  course,  the  former  would  have  no  bearing 
on  postoperative  retention. 

Treatment  of  Postoperative  Cystitis. — In  this  brief  discussion  on 
the  treatment  of  postoperative  cystitis  there  will  be  no  attempt 
to  give  a  detailed  description  of  the  exact  etiologic  factors,  the 
paths  of  infection,  or  the  various  pathologic  changes.  "We  shall 
concern  ourselves  entirely  with  the  ordinary  type  of  acute  inflam- 
mation  which  occasionally  develops  during  the  convalescence  of  a 
surgical  patient. 

The  three  factors  in  the  production  of  cystitis  are  retention, 
trauma,  and  bacteria.  Various  grades  of  retention  are  extremely 
frequent,  both  in  the  male  and  the  female.  There  is  an  entire  lack 
of  appreciation  of  this  fad  with  reference  to  the  female.  So  many 
women  have  small  amounts  of  urine  retention  in  the  bladder  from 
various  causes.  This  retention  is  often  exaggerated  and  sometimes 
made  complete  after  the  administration  of  an  anesthetic  or  op- 
erative manipulations  in  the  vicinity  of  the  bladder.  Trauma  of  the 
bladder  wall,  particularly  in  pelvic  operations  is  very  frequent  in- 
deed, much  more  so  than  is  usually  thought.  If  one  cystoscopes  a 
bladder  following  some  of  the  simplest  pelvic  operations,  there  will 
be  observed  a  diffuse,  extensive  submucous  hemorrhage  throughout 
the  base  and  posterior  wall  of  the  bladder.  It  is  easy  to  see  how  this. 
by  lowering  the  resistance  of  the  bladder  wall  and  interfering  with 
the  mechanical  emptying  capacity,  could,  in  association  with  re- 
tention, play  a  responsible  part  in  the  production  of  bladder  in- 
fection. The  third  factor,  the  active  factor  in  bladder  inflamma- 
tion, is  the  presence  of  bacteria.  We  know  that  bacteria  are  con- 
stantly being  excreted  through  healthy  kidneys  and  pass  out  into 
the  urine.  In  a  normal  untraumatized,  unobstructed  bladder  they 
make  their  exit  without  molest,  but  with  such  an  attractive  medium 
as  stagnant  urine  they  find  a  fertile  field  for  growth.  This,  of 
course,  is  not  the  only  method  of  entrance  for  bacteria  into  the 
stagnant  bladder,  as  they  frequently  enter  through  the  lymphatics, 
either  from  the  bowel,  or  from  the  pelvis,  for  instance  in  pelvic 
inflammatory    disease,    or   possihly   they   may    ascend    through   the 


RETENTION    OF    URINE    AND    CYSTITIS  397 

urethra  or  through  the  blood  stream,  so  that  a  bladder  inflammation 
may  easily  develop  without  the  entrance  into  the  bladder  of  a 
catheter.  However,  with  catheterization  there  are  practically  al- 
Avays  inserted  numerous  organisms.  It  has  been  shown  that  under 
the  strictest  asepsis  innumerable  bacteria  are  introduced  into  the 
bladder  through  instrumentation.  In  the  normal  bladder  this  is 
without  untoward  effects. 

The  lighting  up  of  an  old  chronic  infection  of  the  kidney,  such  as 
pyelitis,  pyelonephritis,  or  a  recrudescence  of  chronic  bladder  in- 
fections, may  be  responsible  for  cystitis  following  operation. 

There  are  to  be  differentiated  from  a  true  cystitis  two  somewhat 
frequent  complications  which  may  occur  postoperatively.  Trigoni- 
tis  or  trigonal  hyperemia  in  women,  and  prostatic  and  posterior 
urethral  inflammation  and  irritability  in  the  male  quite  frequently 
produce  symptoms  which  are  identical  to  those  caused  by  cystitis.  A 
catheterized  specimen  of  urine  will  serve  to  differentiate  the  two,  as 
in  the  latter  the  urine  is  clear  and  uninfected.  Another  symptom 
complex  which  may  occasionally  puzzle  the  attendant  until  urine 
has  been  obtained  is  the  occasional  frequent,  painful  urination, 
which  is  seen  with  a  bladder  which  does  not  empty  itself.  This  is 
quite  common  in  women  past  middle  life.  Just  recently  we  saw  a 
patient  who  was  supposed  to  have  a  cystitis  from  her  symptoms. 
She  was  passing  urine  very  frequently  and  suffering  excessive  pain. 
A  catheter  relieved  a  two  quart  retention  of  urine  and  the  patient's 
symptoms  immediately  subsided.  This  suggests  a  very  careful 
suprapubic  percussion  and  a  urinalysis. 

SymptGms. — A  cystitis  will  usually  make  its  appearance  within 
the  first  week  of  the  postoperative  course,  generally  the  third 
day.  There  is  noticed  an  increased  frequency  and  burning  on 
urination,  often  terminal  pain  with  a  sense  of  dissatisfaction  after  the 
act  of  urination,  and  the  desire  to  make  another  attempt.  Often 
a  suprapubic  pain  and  a  sense  of  pressure,  or  bearing  down  pain  in 
the  lower  abdomen,  occasional  low  backache,  also  occasional  hema- 
turia, which  in  the  acute  cases  is  usually  terminal,  are  present.  With 
such  symptoms  one  may  be  quite  assured  that  cystitis  has  developed, 
even  though  catheterization  has  not  been  done.  A  catheter  speci- 
men of  urine  should  be  carefully  examined,  one  will  usually  find 
pus  and  bacteria,  and  usually  the  colon  bacillus.  There  is  seldom 
fever  in  an  acute  cystitis  unless  there  is  some  coexisting  lesion 
either  in  the  urethra  or  kidney,  so  that  if  a  patient  with  these  symp- 


398  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

loins  has  fever  one  should  certainly  susped  a  renal  infection.  The 
urine  is  usually  acid  as  a  result  of  a  colon  bacillus  infection.  Occa- 
sionally it  is  alkaline  due  to  the  proteus  group,  the  micrococcus  urea 
or  the  staphylococcus. 

Treatment. — As  a  preface  to  our  remarks  on  the  treatment  of  acute 
eystitis  it  may  he  stated  that  almost  invariably  a  frank  cystitis  un- 
der appropriate  treatment  will  be  promptly  relieved  within  a  -week 
or  ten  days.  This  may  be  stated  as  a  golden  rule.  Should  it  not 
respond  one  must  direct  attention  to  some  other  cause,  such  as  an 
associated  vesical,  prostatic  and  seminal  vesicle  lesion  or  an  in- 
flammatory kidney.  This  must  be  borne  in  mind  as  so  many  in- 
dividuals are  treated  for  weeks,  indeed  months,  without  improve- 
ment to  their  bladder  condition,  while  its  running-mate  infection, 
either  above  or  below  is  progressing  to  unnecessary,  and  often 
damaging  developments. 

The  treatment  of  cystitis  may  be  classified  as  follows: 

Prophylactic 

I      Hygienic 
Medical  Dietetic  General 

Therapeutic  Local 

Removal  of  Cause 
Surgical  Curettage  Suprapubic 

<  'y st ostomy  Perineal 

Vesicovaginal  fistula 

Concerning  prophylaxis,  mosl  has  been  said  under  the  paragraph 
devoted  to  urinary  retention.  The  important  things  to  observe  are 
care  during  surgical  manipulation  to  prevent  injury  to  the  bladder 
wall,  and  in  the  case  of  retention  following  operation,  gentle,  care- 
ful cleanly  catheterization  followed  by  the  administration  of  an 
antiseptic  into  the  bladder,  and  vigilance  to  protect  the  bladder 
from  overdistension  in  an  individual  who  is  voiding,  and  the  general 
administration  of  copious  amounts  of  water,  urinary  antiseptics,  and 
careful  attention  to  the  bowels.  Should  a  cystiiis  develop,  medical 
treatment,  either  general  or  local,  usually  suffices  to  promptly  cure 
the  postoperative  type,  and  it  is  seldom  that  one  sees  a  case  neces- 
sitating surgical  interference,  and  then  only  in  cases  of  complicated 
cystitis,  that  is  one  in  association  with  stone,  tumor,  diverticulum, 
or  some  other  abnormality. 

Medical  Treatment. — During  the  acute  symptoms  patients  should 
he  kept  quiet,  instructed  to  drink  freely  of  water,  at  least  a  glass 
or   more    an   hour,    in    order    to    make    the    urine    bland.      Alkaline 


RETEXTIOX    OF    URINE    AND    CYSTITIS  399 

waters  are  given  by  some,  but  plenty  of  good  hydrant  water  is  suffi- 
cient. Patients  should  be  kept  on  light,  nutritious  and  substantial 
food,  avoid  all  condiments,  and  should  not  be  allowed  alcohol  in  any 
form.  Mild  laxatives  such  as  cascara,  phenolphthalein  or  small 
doses  of  saline  in  the  morning,  are  essential.  Local  heat  either 
through  hot  compresses.  hot-water  bag.  or  the  electric  pad.  to  the 
suprapubic  region  are  often  helpful.  Hot  rectal,  or  vaginal  douches 
are  also  extremely  soothing.  The  medical  applications  are  given 
for  a  twofold  purpose:  to  relieve  the  distressing  symptoms  and  to 
combat  the  infection.  For  relief  of  the  pain  and  tenesmus,  ad- 
ministration of  alkalies  is  often  exceedingly  beneficial.  Bicarbonate 
of  soda.  10  to  30  gr.  three  times  a  day.  in  case  of  an  acid  urine,  is 
helpful,  as  it  lessens  acidity,  produces  a  mild  diuresis,  and  has  a 
slight  antiseptic  property.  It  also  possesses  the  advantage  of  not 
disturbing  digestion.  The  alkalies  used  most  frequently  are  potas- 
sium citrate,  potassium  acetate,  and  liquor  potassse.  Combinations 
of  these  drugs  which  are  more  or  less  standard  are  the  following: 

R    Pot.  acetate 

Tinet.  hyoscyam  aa  oz.  1 

"Water  q.s.  oz.  6 

M.  Sig.     Two  teasjjoonsful  in  a  little  water  after  meals. 

IJ    Liquor  potassse  oz.  2 

Ext.   hyoseyam  gr.  x 

Tinet.  opii  eamph.  oz.  1 

Syr.   acacise  oz.  2 

Water  q.s.  oz.  6 

M.  Sig.     One   tablespoon  in  glass   of  water   after  meals. 

For  tenesmus  and  extreme  pain,  anodynes  are  often  necessary. 
A  most  satisfactory  one  is  a  suppository  containing  %  gr.  pow- 
dered opium.  1±  gr.  extract  of  belladonna,  or  a  similar  combination 
containing  double  strength.  The  bromides  are  often  beneficial. 
Triple  bromides,  ammonium,  sodium  and  potassium  prepared  in  an 
effervescent  wafer,  is  a  very  satisfactory  remedy.  Occasionally 
if  the  symptoms  are  hyperacute,  morphine  and  codeine  may  be 
recpiired.  To  combat  the  infection,  internal  antiseptics,  coupled 
with  local  applications  to  the  bladder  are  necessary.  The  most 
efficacious  internal  antiseptic  is  urotropin  for  an  acid  cystitis.  It 
is  often  equally  efficacious  in  alkaline  cystitis  if  the  urine  can  be 
rendered  acid  by  the  administration  of  an  acid-producing  drug. 
Other  antiseptics  in  common  use  are  salol.  benzoic  acid,  acid  sodium 
phosphate,  helmitol,  hetralin.  borovertin,  cystogen.   and  certain  of 


400  AFTER-TREATMENT   OF   SURGICAL   PATIENTS 

the  balsamics,  particularly  sandalwood  oil.  In  gonorrheal  cystitis 
the  balsamics  are  more  applicable.  In  staphylococcus  and  strep- 
tococcus infectious,  urotropiu  is  preferable  in  conjunction  "with 
benzoic  acid  or  acid  sodium  phosphate.  Acid  sodium  phosphate  is 
unquestionably  the  most  valuable  drug  for  acidifying  the  urine. 
Urotropin  should  be  given  in  doses  from  30  to  60  grains  a  day, 
preferably  after  meals  and  at  bedtime  in  conjunction  with  20  gr. 
of  acid  sodium  phosphate.  Various  other  drugs,  such  as  hetralin. 
borovertin.  eystogen,  uraseptin,  methylene  blue  and  others  have 
been  extolled  as  having  superior  qualities,  but  none  possess  the 
efficacious  effect  of  the  substantial  urotropin.  Of  the  balsamics. 
which,  as  has  been  said,  are  particularly  effective  in  gonorrheal 
cystitis,  the  oil  of  sandalwood  stands  preeminent.  It  should  be 
given  in  10  minim  doses,  three  times  a  day  after  meals  and  at 
bedtime.  Numerous  preparations  of  sandalwood  are  on  the  market, 
namely,  gonosan,  arrhovin,  santyl  and  arrhoel.  The  allied  drugs 
are  supposed  to  be  free  from  production  of  disagreeable  gastric 
symptoms.  We  believe,  however,  that  there  is  very  little  difference 
in  this  respect. 

Demulcents  arc  not  as  frequently  used  today  as  formerly.  Such 
drugs  as  buchu,  uva  ursi,  triticum  repens.  flaxseed  lea  and  corn 
silk,  while  soothing,  are  seldom  used  in  urology  today.  Their 
popularity  was  gained  by  their  somewhat  quieting  effect  in  acute 
and  chronic  cystitis  lasting  over  long  periods,  in  uninvestigated 
cases  of  urinary  infections. 

Local  Treatment. — Many  cases  of  acute  cystitis  without  retention 
may  be  cured  by  hygienic  and  dietetic  means,  and  internal  medica- 
tion. The  majority,  however,  arc  hastened  in  their  cure  by  local 
applications  to  the  bladder  itself.  In  the  acute  bladder  infections, 
instillations  are  preferable.  After  catheterizing  the  patient,  in- 
stillation of  2.")  per  cent  argyrol  to  the  empty  bladder  is  most  trust- 
worthy. Even  though  argyrol  is  supposed  to  have  very  little  anti- 
septic quality,  it  is  remarkable  how  quickly  it  will  clear  up  an 
acutely  inflamed  bladder.  Protargol,  1  to  2  per  cent  is  used  by 
Mune.  but  it  is  often  badly  borne  on  account  of  its  irritating  quality. 
Nitrate  of  silver  is  seldom  tolerated  in  the  acute  bladder,  but  it  is 
the  master  of  all  in  chronic  infections.  It  is  surprising  how  quickly 
relief  may  be  obtained  by  a  few  instillations  of  argyrol.  and  as 
has  been  previously  stated,  the  average  cystitis  will  clear  up  within 
a  week  or  ten  days.  Irrigations  are  not  desirable  in  acute  bladder 
inflammation,  as  they  disturb  the  bladder  rest  by  distention  and  are 


EETENTION    OF    URINE   AND    CYSTITIS  401 

not  as  efficacious.  In  the  subacute  or  more  chronic  cases  irriga- 
tions of  potassium  permanganate  1  to  6  to  8,000,  boric  acid  2  to  4 
per  cent  and  bichloride,  1  to  50,000,  silver  nitrate,  1  to  5,000,  and  hot 
saline  solution  are  most  beneficial. 

In  case  of  alkaline  cystitis  which  is  a  very  stubborn,  intractable 
and  painful  type  of  bladder  inflammation,  the  problem  consists  in 
rendering  the  urine  acid  in  order  that  the  alkaline  producing  or- 
ganisms may  not  live.  Various  acid  irrigations  have  been  given, 
but  usually  without  effect.  The  most  helpful,  and  at  times  almost 
magic  treatment  for  such  conditions  is  the  intravesical  injection 
of  Bulgara  bacillus.  Make  an  emulsion  of  4  to  6  tablets,  which  are 
prepared  by  various  drug  houses,  and  inject  through  a  catheter 
into  the  empty  bladder  and  have  it  retained.  This  should 
be  repeated  twice  daily  until  the  urine  is  rendered  acid.  If  the 
cystitis  is  not  complicated  by  a  kidney  lesion,  the  cure  will  be 
prompt.  Even  in  cases  of  incrustation,  we  have  seen  a  rapid  solu- 
tion of  the  incrusted  material  within  forty-eight  hours,  and  a  prompt 
restoration  of  normal  bladder  function  in  a  very  short  period.  In 
case  the  kidney  should  be  involved,  the  administration  of  acid 
sodium  phosphate  in  conjunction  with  the  Bulgara  bacillus  to  the 
bladder  will  be  necessary. 

If  a  cystitis  is  protracted  and  has  not  abated  within  two  weeks, 
one  is  certainly  dealing  with  a  complicated  lesion,  either  a  kidney 
lesion,  some  associated  bladder  phenomena,  such  as  stone,  tumor, 
diverticulum,  bladder  neck  obstruction,  either  mechanical  or  neu- 
rologic, or  one  of  the  many  types  of  chronic  cystitis,  namely,  the 
hemorrhagic,  ulcerative,  vegetative,  or  bullous  type.  The  treatment 
of  these  will  depend  on  thorough  cystoscopic  investigation  and 
study,  and  has  no  bearing  on  the  postoperative  treatment  commonly 
termed.  Therefore  the  surgical  treatment  of  cystitis  need  not  be 
considered  in  this  discussion. 


CHAPTER  XLVIII 

THE  TREATMENT  OF  WOUNDS 
]\y  Willard  Bartlett,  St.  Louis.  Mo. 

Historical  Considerations. — The  healing  of  wounds,  naturally, 
forms  the  oldest  chapter  in  the  history  of  surgery.  Marchand1 
is  authority  for  the  statement  that  Hippocrates,  more  than  two 
thousand  years  ago,  recognized  two  varieties  of  wound  healing, 
one  with  the  format  inn  of  pus,  and  the  other  without  it.  Celsus 
realized  thai  wound  fluids  were  derived  from  the  blood,  while  the 
influence  of  Galen  was  so  marked  upon  the  development  of  this 
subject,  that  it  persists  to  the  present  day.  He  knew,  for  instance, 
that  certain  wounds  heal  without  the  loss  of  substance,  whereas 
others  take  the  contrary  course,  thus  laying  the  foundation  for 
the  use  of  the  terms,  "first  and  second  intention."  His  treatise, 
Ars  Medica,  contains  a  number  of  principles  to  which  we  adhere 
today.  His  influence  is  distinctly  the  most  important  one  that  has 
come  down  to  us.  from  the  remote  past,  and  was  about  all  that  it 
furnished  up  to  the  discovery  of  the  circulation,  the  invention  of 
the  microscope,  and   the  inception  of  experimental  study. 

The  Middle  Ages  produced  practically  nothing  of  value  on  wound 
healing,  so  the  second  period  of  development,  which  has  lasted  to 
the  present  time,  may  be  said  to  have  commenced  with  Schwann's 
discovery  of  the  cell,  which  was  developed  by  Yirchow  in  L855,  in 
his  aphorism  "Omnis  cellula  e  cellula."  A  natural  enlargement  of 
the  idea  came  down  through  the  discoveries  of  Pasteur,  which  were 
applied  to  practical  surgery  by  Lister,  and  marked  the  beginning  of 
the  antiseptic  era.  which  was  later  to  develop  into  our  present 
aseptic  regime. 

Principles  Which  Underlie  Wound  Healing. — The  study  of  the 
subject  may  be  classified  in  many  ways.  Perhaps  as  good  as  any. 
for  general  purposes,  is  a  division  of  wounds  into  ihosc  uniting  by 
"first  intention."  thai  is,  without  loss  of  substance,  and  those  which 
unite  indirectly  after  loss  of  substance  has  been  compensated  by 
granulation  tissue  which  has  changed  into  scar,  this  last  procedure 
being  known  as  "healing  by  second  intention.'' 

ft  can  be  definitely  and  clearly  stated  that  there  is  no  such  thing 
as  absolutely  perfect  asepsis.     It  is  said  that  positive  culture's  of  in- 

102 


TREATMENT    OF    WOUNDS  403 

fective  bacteria  can  be  obtained  in  over  50  per  cent  of  fresh  surgical 
wounds,  and  in  fact,  it  is  safe  to  assume,  at  least,  that  no  wound 
is  ever  made  and  closed  without  a  germ  getting  into  it,  but  for 
practical  purposes;  the  tissues  themselves  take  care  of  a  reasonable 
number,  in  consequence  of  which,  closed  wounds  usually  heal  with- 
out pus  formation.  It  is  quite  a  different  matter  with  wounds  which 
heal  by  second  intention.  These  latter  invariably  become  infected, 
and  it  is  important  that  proper  means  for  the  drainage  of  their 
products  be  furnished,  if  the  patient  is  to  be  spared  the  toxic 
effects  of  bacterial  growth. 

Bier2  was  the  first  to  grasp  the  importance  of  furthering  the  ef- 
forts of  nature  towards  healing  wounds  in  her  own  way,  as  shown 
by  the  invention  of  his  hyperemia  treatment.  He  noted,  very  early, 
that  cyanotic  lungs  are  rarely  tuberculous,  and  rightly  concluded 
that  some  of  the  substances  in  the  dammed  back  blood,  act  as  germ 
destroyers.  He  applied  this  deduction  to  wound  treatment,  in- 
tensifying redness,  heat,  and  swelling,  by  constriction  or  cupping, 
"passive  or  active  hyperemia."  with  the  happiest  results. 

One  can  gain  a  clearer  and  more  comprehensive  idea  of  the 
mechanics  which  aid  repair,  by  reading  John  Hilton's3  little  book 
on  "Rest  and  Pain."  This  admirable  dissertation  was  written  a 
long  time  ago.  but  will  well  repay  a  careful  perusal,  so  long  as  men 
continue  to  practice  surgery. 

The  direction  of  an  incision  in  certain  parts  of  the  body,  has  very 
much  to  do  with  the  nutrition  of  the  wound  edges.  A  fairly  high 
percentage  of  tissue  loss  has  followed  almost  every  method  of  flap 
making,  which  contemplates  complete  closure  after  radical  breast 
operations,  although  in  our  own  experience,  we  have  had  uniformly 
satisfactory  results,  since  using  a  transverse  elliptical  incision,  pro- 
posed by  Stewart.4  This  example  can  be  multiplied  almost  in- 
definitely; no  one.  for  instance,  would  consider  making  a  crescentic 
scalp  flap,  with  the  base  upward,  and  other  illustrations  of  this  rule 
or  precept  will  no  doubt  present  themselves  to  the  reader's  mind. 

Wounds  located  in  regions  particularly  well  supplied  with  blood 
and  lymph,  heal  much  faster  than  those  so  placed  as  to  receive 
a  minimum  amount  of  these  vital  fluids.  Thus,  it  is  a  matter  of 
common  observation,  that  tissues  of  the  face,  for  instance,  heal  much 
quicker  than  do  those  in  other  parts  of  the  body.  For  the  same 
reason,  the  skin  more  quickly  repairs  than  do  the  deeper  tissues, 
as  exemplified  by  fat,  muscle,  fascia  and  bone. 


404  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

The  extent  of  the  cut  also  is  a  factor  in  wound  healing,  which  can 
not  be  overlooked.  After  long  incisions,  the  greater  surface  exposed 
to  infection,  and  the  impossibility  of  perfect  immobilization,  are 
some  of  the  causes  for  the  slow  reparative  processes  frequently  seen 
in  such  instances. 

The  importance  of  this  observation  is  well  borne  out  by  the  be- 
havior of  long  wounds  in  the  aged.  In  them,  tissue  repair  is  much 
slower  than  in  the  young,  and  failure  to  remember  this  has  often 
resulted  in  long  drawn  out  convalescence,  due  to  the  slow  healing 
of  a  needlessly  long  incision.  In  view  of  the  fact  that  these  pa- 
tients should  lie  restricted  as  little  as  possible  after  an  operation, 
careful  attention  to  this  detail  will  not  only  result  in  better  wound 
repair,  but  also,  now  and  then,  be  the  means  of  saving  a  life. 

The  importance  of  having  no  tension  on  wound  edges  can  scarcely 
be  overemphasized;  the  mere  fact  (in  the  event  this  is  not  properly 
attended  to)  that  the  blood  supply  will  lie  cut  off  and  sloughing 
result,  or  stitches  cut  through,  and  wounds  come  open,  is  certainly 
more  than  sufficient  cause  to  commend  a  most  careful  observance 
of  this  importanl  matter.  Incidentally,  it  should  be  mentioned 
that  there  musl  be  no  pressure  by  bandages  or  dressings  on  the  Haps, 
else  nutritional  changes  will  ensue. 

Among  the  general  considerations  to  be  observed,  are  ventilation, 
which  not  only  make;  the  sick-room  habitable,  but  also  directly  con- 
tributes to  the  patient's  increase  in  tone,  which,  as  a  matter  of 
course,  must  underlie  every  healing  process.  The  effecl  of  general 
conditions  on  local  processes,  was  strikingly  illustrated  to  us  re- 
cently. An  anemic  girl  had  experienced  a  thyroidectomy,  and  the 
skin  wound  stubbornly  refused  to  heal,  for  many  weeks.  She  was 
put  to  bed  in  the  hospital,  and  absolutely  nothing  done  but  to  feed 
her  up,  and  keep  the  granulations  clean.  Almost  immediately  a 
marked  improvement  was  observed,  and  in  a  few  days  the  skin 
edges  had  correctly  approximated  themselves. 

We  now  and  then  see  a  Large  wound  which  has  opened  up  spon- 
taneously, although  there  is  no  sign  of  infection,  and  while  it  looks 
clean,  yet  no  evidence  of  repair  is  apparent.  This  can  practically 
always  be  attributed  to  the  influence  of  one  of  the  dyscrasias  which 
prevent  local  reparative  activity. 

Weather  and  temperaturi  are  said  to  exert  a  very  marked  in- 
fluence on  wound  healing,  the  hot.  dry  seasons  and  climates  seem- 
ing to  favor  it.  while  those  in  which  moisture  predominates,  ap- 
parently have  the  opposite  effect. 


TREATMENT   OP   WOUNDS  405 

Phagocytosis  apparently  is  a  matter  of  great  importance  in  the 
healing  of  infected  wounds.  It  has  been  determined  by  Steuber,5 
that  cholesterin  decreases  this  activity,  while  lecithin  completely 
stops  it.  He  states  that  a  bedside  determination  of  these  two  blood 
constituents  is,  therefore,  of  prognostic  value. 

Preexisting  sepsis  is  a  matter  of  great  importance  in  this  con- 
nection. On  one  occasion,  we  were  compelled  to  open  the  abdomen 
of  a  patient  who  had  just  recovered  from  a  severe  influenza,  with 
most  disastrous  consequences  as  far  as  wound  healing  was  con- 
cerned. 

An  operation  performed  during  the  incubation  period  of  any  of 
the  exanthemata  is  extremely  unfortunate.  In  the  experience  of 
the  author  this  influence  was  observed  in  two  cases  of  scarlet  fever, 
one  case  of  measles  and  one  case  of  variola.  In  each  instance  the 
wound  became  infected,  in  spite  of  every  precaution.  Surgical  pro- 
cedures undertaken  in  the  presence  of  such  diseases,  carry  with 
them  the  risk  that  dire  consequences  may  follow,  so  far  as  the 
severed  tissues  are  concerned. 

Laboratory  experimentation  shows  that  pus  infections  of  the  skin, 
within  an  appreciable  distance  of  the  region  to  be  operated,  make 
it  impossible  to  cleanse  such  regions  sufficiently  to  prevent  the 
growth  of  cultures.  Therefore,  patients  with  a  localized  staphy- 
lococcus infection,  much  more  a  generalized  infection,  or  an  ex- 
tensive dermatitis  of  infectious  nature,  can  hardly  be  prepared  for 
operation  with  any  assurance  that  infection  will  not  be  disseminated. 
Chronic  diseases,  such  as  tuberculosis,  diabetes,  arteriosclerosis, 
and  syphilis,  are  particularly  apt  to  cause  delay  in  wound  healing. 
We  have  seen  this  repeatedly  in  patients  with  marked  hardening 
of  the  arteries,  but  after  heavy  doses  of  potassium  iodide,  the 
wounds  in  almost  every  instance  rapidly  closed.  In  none  of  these 
cases  were  we  able  to  find  any  other  explanation  for  the  tissue 
inactivity.  In  patients  suffering  from  syphilis,  breaking  down  of 
any  wound  may  occur.  In  large  clinics,  where  the  lowest  class  of 
patients  are  operated,  mercury  is  given  as  a  routine  measure  to 
prevent  this  so  far  as  possible.  Recently,  a  patient  with  a  perfect 
history  and  negative  physical  examination  was  operated  for  hernia. 
The  wound  refused  to  heal,  though  there  was  no  infection  or  any 
reason  why  it  should  be  obstinate.  The  blood  revealed  a  four- 
plus  Wassermann.  The  patient  was  now  put  on  antisyphilitic 
treatment,  which  resulted  in  the  defect  healing  as  though  by  magic. 

The  very  obese,  or  those  of  generally  lowered  resistance,  due  to 


406 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


varying  causes,  present  difficulties  in  wound  repair,  while  the  poor 
results  obtained  in  the  cachexia  of  extensive  carcinoma  are  well 
known. 

Germ  carriers  are  naturally  not  good  subjects,  a  matter  which 
needs  no  further  elucidation. 

Among  the  more  uncommon  causes  of  faulty  wound  healing,  is  in- 
fection with  the  diphtheria  organism,  as  reported  by  Zeullig.6 

A  special  consideration  must  be  given  wounds  of  the  mucous 
membranes.     As  a  matter  of  course,  none  of  them  can  be  regarded 


Fig.   55.--  A   convenient   wire  basket   containing  the   necessary    materials    foi    dressing   wounds. 

Used   at    Mayo    Clinic. 


as  clean,  hence  they  musl  be  protected  as  far  as  possible.  This  will 
be  taken  up  later  in  connection  with  the  special  regions  involved. 
Early  Treatment  of  Aseptic  or  Closed  Wounds. — After  a  surgical 
wound  has  been  sewed  up.  we  musl  see  t«>  it  that  it  remains  sealed 
against  the  entrance  of  germs,  and  is  protected  from  every  me- 
chanical insult,  until  the  reparative  process  is  well  under  way. 
The  form  of  dressing  will  be  dictated  by  the  region  involved,  as  well 
as  by  a  consideration  of  the  wound  discharges.  In  the  vicinity  of 
external  orifices,  heavy  sterile  vaseline,  or  a  sealed  dressing  (col- 
li, dion.  varnish,  paraffine,  etc.,)  is  admirable  as  a  protection  againsl 


TREATMENT    OF    WOUNDS 


407 


the  possible  ingress  of  the  various  secretions  and  excretions.  In 
other  parts  of  the  body,  the  expected  discharge  of  blood,  serum,  or 
lymph,  from  a  clean  wound,  would  naturally  presuppose  the  im- 
mediate application  of  a  sterile,  voluminous,  absorbent  dressing. 

\Vhen  shall  the  dressing  on  a  sterile  wound  be  changed?  This  is 
a  question  which  is  difficult  to  answer  in  a  general  way,  since 
individual    wounds,    as   a    matter    of    course,    make    individual    re- 


Fig.   56. — Large  basket  containing  materials  used  in  treatment  of  wounds. 


Fig.   57. — A  water  bottle  which  may  be  maintained  at  any  temperature  by  means   of  a 
stream  of  water  passing  through  it. 


quirements.  It  may,  however,  be  stated  for  most  patients,  that  an 
inspection  of  the  dressing,  or  the  patient's  sensations  of  discomfort, 
or  a  glance  at  the  temperature  chart,  or  all  three  of  these  combined, 
will  very  readily  settle  the  matter,  (Figs.  55,  56  and  57.)  Where 
no  drain  has  been  left  in,  and  there  is  no  cosmetic  reason  for  the 
early  removal  of  sutures,  where  the  patient  is  comfortable  and  there 
is  no  marked  rise  in  temperature   or  pulse,   it  is   common  in  our 


408 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


practice  to  alloAV  the  original   dressing-  to   remain   in  place  about 
one  week. 

When  shall  a  drain  lie  removed  after  septic  operations?  Gener- 
ally speaking,  there  is  no  reactionary  hemorrhage  after  twenty-four 
hours,  hence,  a  drain  which  is  expected  to  conduct  away  blood 
can  usually  be  removed  at  the  expiration  of  this  period,  ('lean 
wounds  must  often  be  drained  for  lymphorrhagia  niter  the  dissec- 
tion of  the  inguinal,  cervical,  and  other  similar  regions,  but  these 
drains  must  usually  be  left  in  place  for  several  days,  and  be  re- 
moved when  the  dressings  no  longer  become  soaked. 


Fig.   5S- — Stitch   pulled   up   and   cut   through   portion    that   was   buried   in    skin. 


Scars  upon  the  face  and  neck  arc.  as  a  mailer  of  course,  and  if 
at  all  possible,  to  be  avoided.  In  order  that  this  "consummation, 
so  devoutly  to  be  wished"  may  be  attained,  it  is  necessary  to  pay 
attention  to  a  number  of  details,  among  which  may  be  mentioned 
the  early  removal  of  stitches,  say  in  one  or  two  days,  if  a  deeper 
layer  has  been  firmly  sutured.  This  early  removal  of  the  stitches 
invariably  prevents  the  unsightly  si  itch  cross-marks  which  one  so 
frequently  sees  on  scars  not  so  happily  Healed.  In  other  parts 
of  the  body,  Ave  allow  the  skin  stitches  to  remain  about  a  week 
(Figs.  58-61.)  Agglutination  transpires  within  twenty-four  hours, 
and  after  a  week's  time,  considerable  fibrous  union  is  noted. 


TREATMENT    OF    WOUNDS 


409 


"Through-and-through"  stitches  are  removed  in  ten,  twelve,  or 
fourteen  days,  according  to  whether  the  patient  is  quiet,  provided 
they  do  not  cut  and  become  too  painful;  this  latter  contingency  is 
however,  unlikely  to  occur  if  the  stitches  have  been  run  through 
thin  rubber  tubing  or  been  tied  over  other  material,  which  protects 
the  skin. 

Patients  are,  almost  without  exception,  nervous  and  apprehensive 
of  suture  removal.  In  order  to  avoid,  or  indeed,  eliminate  this  un- 
necessary strain  as  much  as  possible,  we  have  often  found  it  ex- 
pedient to  inform  the  individual  that  our  intention  is  to  remove  the 


Fig.  59. — Dividing  and  removing  superficial  stitches. 

sutures  the  following  day,  and  thereupon,  to  proceed  immediately 
to  that  very  step.  In  this  way  he  is  spared  hours  of  uneasy  and 
unhappy  imaginings. 

Severe  pain  may  some  times  be  lessened  by  counterpressure  on  the 
skin  while  pulling  upon  the  stitches. 

If  liquid  fat,  lymph  or  blood  serum  collects  in  a  wound  that  has 
been  tightly  sewed  up.  it  is  advisable  to  spread  the  edges  a  short 
distance  by  thrusting  forceps  into  the  cavity  and  opening  the 
jaws,  after  which,  a  strip  of  rubber  dam  is  to  be  inserted.  A  few 
hours  of  this  treatment  will  usually  be  found  to  be  all  that  is  neces- 
sary, and  the  drains  may  then  be  removed. 


410 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


Stitch  infections  are  painful,  as  a  rule.  They  may  be  recognized 
by  a  circumscribed  redness  around  the  stitches,  and  naturally,  they 
demand  immediate  removal  of  sutures,  after  which,  they  will  usu- 
ally heal  spontaneously;  although  sometimes  they  may  demand  dila- 
tation, and  the  insertion  of  rubber  drains,  when  abscesses  have 
formed. 

Early  Treatment  of  Infected  or  Open  Wounds. — Too  much  can 
not  be  said  regarding  the  importance  of  asepsis  when  employed  to 
prevent  us  engrafting  tetanus  or  other  infections  into  already  sup- 


ture. 


purating  wounds.  The  treatment  of  infected  wounds  resolves  it- 
self into  a  comparison  between  forms  of  drainage  as  against  an- 
tisepsis, which  latter  is  certain  to  cause  coagulation  of  the  ex- 
cretions. We  consider  the  drainage  of  any  open  wound  to  be  the 
matter  of  major  importance,  while  the  chemical  destruction  of 
bacteria,  as  formerly  practiced,  was  nol  only  of  doubtful  value,  but 
indeed,  harmful,  since  drainage  was  impaired. 

The  use  of  hypertonic  solutions  of  various  sorts  has  been   found 
to  promote  drainage,  while  in  my  own  experience,  glycerin  (hygro- 


TREATMENT    OF    WOUNDS 


411 


scopic)  (Figs.  62  and  63)  has  besn  the  most  efficient  agent  of  this 
kind  I  have  ever  used.  In  closed  dressings  it  depletes  tissues  rapidly, 
and  gives" immediate  relief  from  pain.  It  is  universal  in  its  applica- 
tion, and  although  the  cheaper  grades  contain  sulphuric  acid,  and 
hence,  are  highly  irritating,  yet  this  may  be  readily  ascertained  and 
easily  avoided.  An  excellent  vet  (Figs.  64-68)  dressing  is  glycerin, 
peroxide  of  hydrogen,  and  distilled  water,  equal  parts.  We  have 
used  this  for  many  years,  especially  where  dirty  wounds  are  to  be 


Fig.   61. — Cleaning  the  wound  after  stitches   have  been   removed. 


cleaned  up  rapidly.    An  admirable  dressing  for  painful  granulating 
surfaces,    is   Una's    Mixture,    which    is    made    after    the    following 

formula  : 

Amyluni    and.    Talcum,    each  100  grams 

Glycerin  40  grams 

Liq.    Plumbi    subacetate,    dilute,  200  grams 

This  is  to  be  thoroughly  shaken  and  poured  on  cotton  to  be 
covered  with  gutta  percha,  and  changed  every  few  hours.  It  gives 
a  most  delightful  sensation  of  relief  and  cooling. 


412 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


utely  inflamed   scrotum   and   :  ich   glycerin   rack  is  about  to  be   applied. 


Fig.   63. — Same   scrotum  and  penis  after  twenty-four   hours'   application  of  glycerin   pack. 


TREATMENT   OF    WOUNDS 


413 


There  can  be  no  set  rule  for  the  frequency  of  changing  wet  ab- 
sorbent dressings.  This  must  occur  as  often  as  they  become  satu- 
rated or  foul. 

Ways  of  keeping  dressings  in  place  will  be  discussed  under 
"Bandaging,"  and  in  other  places  in  this  book,  but  I  shall 
mention  just  a  few  special  devices  here.  Dressings  for  breast 
wounds  may  be  attached  to  underwear.  This  applies  to  a  less  extent 
to  other  portions  of  the  trunk,  where  gauze  and  cotton  are  not  easily 
kept  in  place,  and  when  patients  experience,  more  or  less,  the  dis- 
comfort caused  by  the  slipping  of  the  bandage.     Adhesive  plaster 


Fig.  64. — First  step  in  making  cotton  pledgets. 

(Fig.  69)  has  been  found  very  satisfactory  for  this  purpose,  as  it 
holds  the  dressings  immobile,  neither  is  it  necessarily  removed  at 
each  dressing.  The  plaster  should  be  cut  in  the  middle  and  folded  back 
when  the  dressing  is  changed,  and  adjoining  ends  be  refastened  with 
tape  or  safety  pins  (Figs.  70  and  71).  In  order  that  the  adhesion 
may  be  perfect,  all  surfaces  to  which  adhesive  plaster  is  applied 
should  be  shaved  and  rendered  absolutely  dry,  or  hairy  parts  may 
be  conveniently  treated  with  a  depilatory,  the  chief  ingredient  of 
which  is  calcium  sulphide  dissolved  in  water.  Fenestrated  adhesive 
plaster,  which  allows  the  escape  of  perspiration,  is  to  be  recom- 


414 


AFTER-TREATMENT    OF    SURGICAL   PATIENTS 


mended  in  that  it  is  more  comfortable  to  the  patient  and  less  likely 
to  cause  itching  and  dermatitis. 


Fig.   65. — Second  step  in  making  cotton  pledgets. 


Fig.   66. — Third  step  in  making  cotton  pledgets. 

A  sterilizing  agenl  long  Lauded  by  German  authors,  is  balsam  of 
Peru.     This  is  injected  into  wound  cavities  and  applied  on  wound 


TREATMENT    OF    WOUNDS 


415 


surfaces.  Blumberg7  conducted  a  series  of  the  most  thorough  and 
exhaustive  experiments  in  the  use  of  this  agent,  and  found  it  a 
most  valuable  one  in  the  successful  handling  of  fresh,  primary, 
dirty  wounds,  as  well  as  in  cases  where  granulations  were  present. 


Fig.    67. — Small   covered  basins  fo 


mg   antiseptic 


unions.      Used   at    Mayo    Clinic. 


Fig.    68. — Washing   lip   of   alcohol   bottle   before   pouring   the   liquid    on   a   cotton 


Dakin's  Fluid,  a  product  of  the  present  great  war,  is  the  sensa- 
tion of  modern  times,  so  far  as  wounds  are  concerned.  Dr.  C.  L. 
Gibson8  returned  from  France,  early  in  the  Fall  of  1916,  and  told 
us  that  the  minority  of  the  surgeons  then  working  in  France  were 


416 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


enthusiastic  over  Dakin's  fluid,  while  the  majority  thought  un- 
favorably of  it.  Surgeons  of  the  laboratory  type  claim  wonderful 
results  for  it,  while  the  eminent  clinician  in  America  will  have 
none  of  it. 

It  seems  that  Carrel,  who  gives  extensive  personal  care  to  many 
little  details  of  treatment,  uses  the  fluid  with  the  highest  measure 
of  success,  while  Du  Page,  who  has  eighl  hundred  beds  at  Le  Pan, 
is  equally  successful,  for  the  reason  that  he  carefully  follows  the 
Carrel  regime.  With  Hie  exception  of  Dr.  Henry  Lyle,  of  New 
York,  no  one  else  seems  to  have  followed  out  Carrel's  technie 
in  the  entirely,  and  this  accounts,  in  Dr.  Gibson's  opinion,  for  the 


Fig.   69. — Use  of  ordinary  adhesive   for  holding  dressings  in  place. 

fact  that  the  fluid  lias  not  been  more  widely  used  with  success. 
Gibson  saw  Carrel]  do  the  first  dressings  in  a  number  of  cases, 
where  an  infected  compound  fracture  had  been  treated  with  Dakin's 
fluid,  and  then  sewed  up  tightly.  In  not  one  instance  was  there 
a  disturbance  of  wound  healing.  He  also  saw  Dn  Page  dress  eighty 
compound  fractures  in  four  hours,  without  a  drop  of  pus  being 
apparent,  many  of  these  having  been  first  treated  with  Dakin's 
fluid,  before  the  wounds  were  sewed  up. 

In  Hie  early  days  of  Dakin's  fluid,  flic  solution  was  not  properly 
made,  and  proved  to  lie  too  highly  caustic,  hence,  it  has  been 
altered,  the  composition  now  being  as  follows,  according  to  the 
so-called  technie  of  Dr.  Daufresne : 


TREATMENT    OF    WOUNDS 


417 


The  solution  of  sodium  hypochlorite  for  surgical  use  must  be  free  of  caustic 
alkali;  it  must  only  contain  0.45%  to  0.50%  of  hypochlorite.  Under  0.45%  it 
is  not  active  enough  and  above  0.50%  it  is  irritant. 


Fig.   70. — Attaching  gauze  tapes  to  adhesive. 


Fig.  71. — Gauze  tapes  tied  so  that  adhesive  does  not  have  to  be  pulled  off  skin  when 

changing  dressings. 


With  chloride  of  lime  (bleaching  powder)  having  25%  of  active  chlorine, 
the  quantities  of  necessary  substances  to  prepare  10  liters  of  solution,  are  the 
following: 

Chloride  of  lime   (bleaching  powder)   25%   of   CI.   act.         200  gr. 

Sodium  carbonate,  dry,   (soda  of  Solway)  100  gr. 

Sodium  bicarbonate  80  gr. 


418  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

Put  into  a  12  liter  flask  the  two  hundred  grams  of  chlorine  of  lime  and  five 
liters  of  ordinary  water,  shake  vigorously  for  a  few  minutes,  and  leave  in 
contact  for  sis  to  twelve  hours:  one  night  for  example. 

At  the  same  time  dissolve  in  five  liters  of  cold,  ordinary  water,  the  car- 
bonate and  bicarbonate  of  soda. 

After  leaving  from  six  to  twelve  hours,  pour  the  salt  solution  in  the  flask 
containing  the  macerated  chloride  of  lime,  shake  vigorously  for  a  few  minutes, 
and  leave  to  allow  the  calcium  carbonate  to  be  precipitated.  In  about  one- 
half  hour,  siphon  the  liquid  and  filter  with  a  double  paper  to  obtain  a  good 
clear  liquid,  which  should  always  be  kept  in  a  dark  place. 

Titration  of  Chloride  of  Lime  (Bleaching  Powder). — Because  of  the  varia- 
tion of  the  products  now  obtained  in  the  market,  it  is  necessary  to  determine 
the  quantity  of  active  chlorine  contained  in  the  chloride  of  lime  which  is  to 
be  used.  This  is  in  order  to  employ  an  exact  calculated  quantity  according  to 
its  concentration. 

The  test  is  made  in  the  following  manner:  Take  from  the  different  parts 
of  the  jar  a  small  quantity  of  bleaching  powder  to  have  a  medium  sample; 
weigh  29  grams  of  it,  mix  as  well  as  possible  in  a  liter  of  water  and  leave  in 
contact  a  few  hours.  Measure  1"  c.e.  of  tin-  clear  fluid  and  add  20  c.c.  of  a 
10%   solution    of    iodide    potass  -   c.c.    of   acetic    acid    or  hydrochloric    acid. 

then  put,  drop  by  drop,  into  the  mixture  a  decinormal  solution  of  sodium  hy- 
posulphite -  18  until  decoloration.  The  number  of  cubic  centimeters  of 
hyposulphite  employed,  multiplied  by  1,775,  will  give  the  weight  A"  of  active 
chlorine  contained  in    LOO  g        -   of  chloride  of  lime. 

The  test  must  be  made  every  time  a  new  product  is  received.  When  the  re- 
sult obtained  will  differ  more  or  less  than  25%,  it  will  be  necessary  to  reduce 
or  enlarge  the  proportion  of  the  three  ]  inducts  contained  in  the  preparation. 
This  -  ined  by   multiplying  each  of  the  three  numbersj    - 

100.  mi,  by  the  factor  42.1.  in  which  X.  represents  the  weight  of  the  active 
chlorine  percentage  of  chloride  of  lime. 

Titration  of  Dakin  Solution. —  Measure  1"  c.c.  of  the  solution,  add  20  c.c. 
of  potassium  iodide  1  10,  2  c.c.  of  acetic  acid  and,  drop  by  drop,  a  decinormal 
solution  of  sodium  hyposulphite  until  decoloration.  The  number  of  cubic 
eentimel  -  •  1  multiplied  by  0.03725  will  give  the  weight  of  hypochlorite  of 
soda  contained  in  100  c.c.  of  the  solution. 

Never  heat  the  solution  and  if  in  a  case  of  urgency  one  is  obliged  to  re- 
sort to  trituration  of  chloride  of  lime  in  a  mortar,  only  employ  water,  never 
salt  solution. 

Test  of  the  Alkalinity  of  Dakin  Solution. — To  easily  differentiate  the  solu- 
tion obtained  by   this   process  from  the   commercial  hypochlorites,  pour  into  a 
about  2o  c.c.  of  the  solution  and  drop  on  the  surface  of  the  liquid  a  few 
centigrams  of  phenolphthaleine  in 

The  correel  solution  does  not  give  any  coloration  while  Labarraque's  so- 
lution and  Eau  de  Javel  will  give  an  intense  red  color  which  shows  in  the  last  two 
solutions  existence  of  free  caustic  alkali. 

Ill  the  treatment  of  a  wound,  a  great  deal  depends  upon  the  fluid 
reaching  every  little  cavity,  hence,  four  rubber  tubes  are  con- 
nected to  a  glass  apparatus    Fig.  72  .    These  are  closed  at  the  outer 


TREATMENT    OF    WOUNDS 


419 


ends,  and  perforated  with  many  small  openings,  so  the  fluid  in- 
jected through  them  is  widely  diffused.  The  surface  of  the  wound 
is  kept  damp  but  not  flooded.  Irritation  of  the  surrounding  skin  is  pre- 
vented by  the  liberal  use  of  vaseline  on  a  cloth.  The  reservoir  is 
held  one  meter  above  the  wound,  and  frequently,  six  to  ten  of  the 
glass  connecting  rods,  previously  mentioned,  each  equipped  with 
four  rubber  tubes,  are  employed  in  a  large  defect,  A  very  small 
dressing  is  used,  just  a  layer  or  two  of  gauze,  on  which  the  glass 
connecting  rods  lie.  This  dressing  is  changed  every  day.  and  if 
all  the  pockets  are  reached,  germs  rapidly  disappear  from  the 
wound.  Matter  which  is  obtained  as  a  fresh  smear,  is  taken  and 
examined  daily;   in  ten  days  or  two   weeks,   the  wound  becomes 


V  .,-;..:    '■•% 

WfW 

n 

n~fl 

B^L  ^  £H 

m  ^fi 

JL*  Ms 

W     '    v 

J 

w 

Fig.  72. — The  Carrel-Dakin  glass  distributor. 


sterile ;  when  it  remains  sterile  for  about  six  days,  the  edges  are 
trimmed  with  a  scissors  and  the  whole  tightly  sewed  up. 

Surfaces  are  prepared  for  skin  grafting  in  the  same  way,  and 
Gibson  reports  astonishing  successes  for  it.  He  saw  some  such 
areas  dressed  four  days  after  the  grafting  on  granulations,  and 
they  were  perfectly  dry. 

It  may  be  added  that  Carrel  considers  the  method  complicated, 
at  the  present  time,  and  is  trying  to  produce  a  much  simpler  one. 
Dr.  Lyle,9  who  has  just  returned  from  the  front  in  France  says: 
"The  Carrel  method  of  disinfecting  wounds  is  based  on  the  follow- 
ing conception :     To  render  an  infected  wound  sterile,  it  is  neces- 


420  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

sary  to  employ  a  suitable  antiseptic  in  such  a  manner  that  the 
chosen  antiseptic  comes  in  contact  with  every  portion  of  the  wound, 
that  the  antiseptic  is  maintained  in  a  suitable  concentration  through- 
out the  entire  wound,  and  that  this  constant  strength  is  maintained 
for  a  prolonged  period.  If  these  conditions  are  fulfilled,  every 
wound  will  show  its  response  to  the  treatment  by  the  diminution 
and  disappearance  of  its  microorganisms.  The  chemical  destruc- 
tion of  the  microorganism  of  a  wound  depends  on  the  difference 
of  resistance  existing  between  the  tissues  involved,  and  the  bac- 
teria present  on  their  surfaces." 

He  summarizes  his  conclusions  on  this  subject  as  follows:  "The 
future  course  of  the  wound  is  directly  dependent  on  the  thorough- 
ness of  the  first  surgical  act.  This  should  be  carried  out  under  the 
strictest  aseptic  precautions  and  at  the  earliest  possible  moment. 
It  consists  of  a  thorough,  methodical,  mechanical  disinfection  of  the 
wound  with  the  extraction  of  all  shell  fragments,  particles  of  cloth- 
ing, dirt,  etc. 

"The  Carrel  method  is  not  a  continuous  irrigation.  It  is  not  de- 
pendent on  the  miraculous  power  of  an  antiseptic,  or  on  any  one 
feature  of  the  method,  but  on  the  combination  of  the  whole.  It  is 
a  method  of  sterilizing  wounds  by  mechanically  delivering  an  an- 
tiseptic of  definite  chemical  concentration  to  every  portion  of  a 
surgically  prepared  wound  and  insuring  its  constant  contact  for 
a  prolonged  period.  The  progress  of  the  sterilization  is  rigorously 
controlled  by  the  microscope.  Gentleness,  thoroughness,  and  at- 
tention to  detail  are  essential  for  success.  I  firmly  believe  that 
the  adoption  of  this  method  is  destined  to  save  many  lives,  to  re- 
duce the  gravity  of  the  mutilations,  and  allow  the  rapid  return  to 
the  front  of  many  men  who  would  otherwise  be  lost  to  the  service 
of  their  country." 

In  a  recent  personal  communication.  Dr.  \Y.  C!.  Fralick  writes 
us:  "The  great  impetus  which  has  been  given  to  the  use  of  the 
Drs.  Carrel  and  Dakin  Hypochlorite  in  surgery,  through  widely 
published  reports,  would  seem  to  warrant  our  giving  to  the  pro- 
fession the  most  intimate  knowledge  we  have  of  their  chemistry 
and  bactericidal  effects,  together  with  technical  reasons  for  fl 
preference  of  a  particular  hypochlorite,  for  clinical  use.  My  re- 
search work  with  the  halogen  compounds  extends  over  a  period 
of  more  than  15  years,  and  deals  with  methods  of  preparation,  their 
chemistry  and  bactericidal  action,  together  with  their  surgical  ap- 
plication on  deep  and  superficial  wounds,  intraperitoneally  and  in- 


TREATMENT    OF    WOUNDS  421 

travenously;  also  their  action  and  dissolving  power  on  infected 
blood  clots  and  necrotic  tissue." 

Hypo  chlorous  acid,  as  a  medium  for  wound  treatment  has  received 
wide  commendation;  among  others,  Dalton10  reports  a  series  of 
fifty-seven  cases,  thus  treated.  The  results  obtained  were  uni- 
formly excellent.  Fraser11  tells  us  that  the  solution  has  been  used 
with  inestimable  benefit  in  gas  gangrene,  and  in  compound  frac- 
tures, complicated  by  infection.  Again  the  Medical  Research  Com- 
mittee12 of  the  Royal  College  of  Surgery  of  Edinburgh,  advocates 
the  application  of  eusol,  and  praises  its  use  in  wounds  which  have 
become  septic  after  certain  operations,  and  considers  that  it  has 
been  proved  nontoxic  and  nonirritating.  as  well  as  an  efficient  an- 
tiseptic. 

The  specific  use  of  antiseptics  is  well  brought  out  by  Oehsner13 
when  he  writes  that  he  believes  our  physicochemical  experiments. 
biochemical  studies,  bacteriologic  investigation  and  clinical  experi- 
ence are  corroborative,  and  justify  the  following  conclusions,  viz : 
that  osmosis  is  a  purely  chemical  process;  that  boric  acid,  when  ap- 
plied to  the  surface  of  the  body  in  a  saturated  aqueous  solution, 
is  absorbed  in  appreciable  quantities  by  a  process  of  osmosis  similar 
to  the  process  studied  in  the  chemical  laboratory ;  that,  when  used 
in  cases  of  septic  infection,  it  is  most  potent  in  reducing  the  viru- 
lence of  certain  pathologic  bacteria;  but.  that  in  order  to  be  ef- 
fective, it  must  be  applied  in  saturated  solution,  and  finally,  that 
when  applied  as  above  directed,  in  the  early  stages  of  septic  infec- 
tion, most  eases  will  make  a  complete  recovery  without  incision, 
without  the  loss  of  any  member,  and  without  permanent  impairment 
of  function. 

He  also  states  that  he  has  come  to  the  point  where  he  looks 
upon  this  dressing  as  almost  specific  in  streptococcus,  Staphylococcus 
albus  and  citreous  infections  of  the  skin  and  cellular  tissue,  as  well 
as  in  pemphigus,  and  that  in  order  not  to  be  disappointed  in  our 
use  of  boric  acid  wet  dressings,  it  is  important  that  we  make  a 
diagnosis  as  to  the  nature  of  the  infection.  As  a  rule  this  can  be 
done  easily,  at  least  one  can  practically  always  say  whether  a  case 
is  one  of  malignant  edema,  tuberculosis,  or  impetigo  contagiosa, 
and  it  is  only  in  these  three  infections  that  boric  acid  is  contra- 
indicated. 

Beck  seems  to  have  injected  bismuth  paste  with  good  results 
(Fig.  73). 


422  AFTER-TREATMEXT   OF    SURGICAL   PATIENTS 

One  of  the  most  important  recent  innovations  is  well  described 
by  Dyes,  who,  in  discussing  the  treatment  of  infected  wounds  says: 
Heat  and  moisture  are  essentially  necessary  for  the  growth  and  de- 
velopment of  pathogenic  bacteria,  consequently  tissue  destruction  is 
greater  in  moist,  than  dry  gangrene.  He  calls  attention  to  the  fact 
that  the  Indians  preserved  their  meats  by  placing  the  carcasses 
high  above  the  ground  and  exposed  to  the  air  and  sunlight.  He 
also  comments  upon  Ihe  fact  that  domestic  animals  rarely  have 
suppurating  wounds,  and  that  these  wounds  are  kept  open  and  clean 
by  constant  licking.     In  conclusion,  he  remarks  upon  the  success- 


I  he   injection   of   Beck's   bismuth   paste. 

t'nl  treatmenl  of  burns  by  the  open  method,  and  mentions  the  remarka- 
ble results  attained  by  Rollier  by  this  mode  of  procedure  in  surgical 
tuberculous  affections.  The  method  pursued  by  Dyes  is  as  follows: 
The  patient  is  put  to  bed.  A  cradle  (Figs.  7-4  and  75)  is  placed 
over  the  affected  part,  over  which  a  mosquito  netting  is  placed  as  a 
protection  againsl  Hies  and  flying  crusts.  In  some  instances,  a 
small  electric  fan  is  turned  on  the  lesion,  and  kepi  going  for  from 
fifteen  minutes  to  half  an  hour,  four  or  five  times  a  day.  Only  an 
occasional  raising  of  the  crusts,  to  allow  the  escape  of  serum  or  the 
irrigation  of  a  stubborn  area  for  a  time,   is  permitted.     An  inert 


TREATMENT    OF    WOUNDS 


423 


Fig.  ;i.— a 


under  which  a  large   surface  may  be  kept  exposed. 


Fig.   75. — A  small  shield  for  exposing   a  small   area. 


424 


AFTER-TREATMENT    OF    SURGICAL   PATIENTS 


desiccating  powder  is  used  at  times,  and  in  ambulatory  cases, 
wounds  are  protected  by  a  wire  screen  held  on  by  adhesive  plaster. 
I  have  made  extensive  use  of  the  method,  and  found  it  em- 
inently satisfactory.  The  patient  is  comfortable,  the  surrounding 
skin  stays  healthy,  much  money  is  saved,  as  no  dressing  need  be 
bought,  and  all  in  all.  it  has  answered  every  requirement  very  well. 
I  combined  it  with  Crile's15  electric  light  treatment  and  found  the 
combination  particularly  applicable  to  the  treatment  of  suppurating 
abdominal  lesions,  such  as  those  of  the  appendix.  Caput  in  1914 
first  discovered  that  electric  light  would  take  the  place  of  the  sun- 
light in  the  healing  of  wounds.  In  fact,  analysis  shows  the  two 
rays  to  be  similar.     At   the  present  time  I  am  treating  two  fecal 


Fig.  76. — An  automatic  glass  rubber  cupping  device. 


fistulas  in  this  manner.  The  patient  is  Ear  more  comfortable,  and 
indeed  much  better  off  than  with  voluminous  dressings  soaked  with 
feces.  The  entire  abdomen  is  covered  by  a  cradle  which  supports 
the  light  and  at  the  same  time  holds  the  bed  clothes  at  a  distance. 
In  smaller  wounds,  I  use  an  ordinary  wire  gauze  strainer  from 
a  hardware  store,  as  a  protection,  and  am  careful  to  see  that  there 
is  an  electric  lighl  near  by.  or  that  sunshine  falls  on  them  from  a 
near-by  window. 

There  arc  certain  infected  wounds  which  are  best  treated  by 
suction  cupping.  This  will  he  found  to  relieve  edema;  it  remove's 
secretions,  eases  pain,  and  in  general,  facilitates  rapid  repair.     Fur- 


TREATMENT    OP    WOUNDS 


425 


uncles  (boils)  form  excellent  examples  of  this  class  of  wounds.  In 
a  case  which  could  not  be  aborted,  but  has  had  to  be  operated 
upon,  if  sufficient  time  has  elapsed  before  the  incision  is  made, 
the  necrotic  center  of  the  lesion  can  be  lifted  out  at  once ;  but  if  it 
is  not  loose,  gentle  suction  (Figs.  76  and  77)  should  be  employed 
every  hour  or  so,  the  wound  being  merely  covered  by  a  vaccination 


Fig.   77. — A  positive  suction  cupping  device. 

shield  and  exposed  to  the  rays  of  an  incandescent  bulb,  placed  so 
close  to  it  as  to  produce  an  agreeable  degree  of  warmth. 

A  fifteen  watt  lamp  gives  a  delightful  sense  of  warmth,  as  the 
recent  experience  of  the  author  has  demonstrated,  while  the  or- 
dinary green  metal  household  shade  protects  surrounding  parts 
from  heat  and  light.  In  a  short  time  the  necrotic,  center  can  be 
sucked  out  in  toto,  after  which  the  defect  rapidly  granulates  up, 


42G 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


and  no  further  treatment  is  needed  than  the  occasional  cleansing 
with  alcohol  to  prevent  the  reinfection  of  the  surrounding  skin 
openings,  and  the  protection  of  the  wound  with  a  vaccination 
shield. 

Suppose  The  lesion  is  on  the  hack  of  the  neck,  and  any  form 
of  circular  bandage  be  worn.  Painful  pressure  and  distressing 
massage  of  the  Lesion  are  unavoidable  every  time  the  head  is  turned. 
The  patient  endeavors,  by  using  all  of  the  neck  muscles,  to  hold  the 
field  at  rest,  and  very  soon  excessive  local  fatigue  added,  makes  his 
lot  still  more  unhappy.     It  may  be  further  said  that  any  form  of 


venicnt  way   of  storing  sterile  gauze  packing  in   glass   talus. 

dressing  makes  a  pus  poultice,  and  accounts  in  a  greal  measure  for 

the  reinfect  ions  and  for  neighboring  si adary  furuncles;  on  the 

other  hand,  the  growth  of  bacteria  is  hindered  by  the  drying  up  of 
excretions  from  a  wound  exposed  to  the  air. 

This  treatment  may  lie  carried  out  by  any  intelligent  member 
of  a  family  or  office  force,  which  brings  it  veil  within  the  range  of 
possibility  for  many  men.  withoul  upsetting  the  ordinary  routine 
of  life.  If  carried  mil  faithfully,  with  regard  (<>v  every  detail,  it 
robs  this  distressing  malady  of  its  mosl  serious  features.     Tin'  sorl 


TREATMENT    OF    WOUNDS 


427 


of  "stock"  affected  by  horsemen  and  golfers,  can  readily  be  worn 
over  the  vaccination  shield,  and  the  patient  be  rendered  somewhat 
uncomfortable,  though  much  more  presentable,  than  is  the  case 
when  an  otherwise  well-groomed  man  with  a  stiff  neck,  goes  about 
minus  collar  and  tie,  with  a  surgical  bandage  where  they  should  be. 

The  suction  rapidly  reduces  the  edema  in  adjacent  muscles, 
with  the  consequent  early  disappearance  of  the  stiff  neck  so  charac- 
teristic of  the  condition. 

Generally  speaking,  the  irrigation  of  infected  wounds  has  almost 
passed  out  of  use.  I  vividly  recall  a  case  of  axillary  abscess, 
many  years  ago,  which  was  treated  by  daily  irrigation.  The  tem- 
perature rose  to  104°  within  an  hour  after  each  treatment.  The 
treatment  was  discontinued,  but  left  a  memory,  never  to  be  for- 


Fig. 


'9. — Granulations   covered  with   gutta  percha  which  protects   them   from   gauze  dressings 
which  would  otherwise  adhere. 


gotten.  Mention  of  daily  gauze  packing  (Fig.  78)  of  defects  is 
made,  only  to  be  condemned.  It  is  not  only  highly  painful,  but 
at  the  same  time,  gauze  retains  the  secretions  and  becomes  foul. 
"Where  gauze  (Fig.  79)  must  come  in  contact  with  granulations  at 
all,  it  is  perhaps  well  to  consider  Fisher's16  suggestion  that  plain 
surgical  gauze  is  unsatisfactory,  where  it  adheres  to  granulating 
wounds,  a  disadvantage  which  is  less  troublesome  if  narrow  mesh 
gauze  is  used.  Xo  particular  advantage  attaches  itself  to  medicated 
gauze.  (Figs.  80  and  81.)  He  considers  that  he  secured  the  best 
results  from  the  use  of  gauze  impregnated  with  paraffme  treated 
in  the  following  manner :  eight  parts  of  paraffme  mixed  with  two 
parts  of  white  petrolatum  and  lanolin  boiled  for  ten  minutes. 


428 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


Drainage  is  "well  employed  in  the  removal  of  lymph,  liquid  fat, 
blood  or  pus.  The  length  of  the  period  over  which  it  is  to  be  con- 
tinued must  be  determined  in  each  individual  case.  As  to  drainage 
material,  I  shall  preface  this  subject  by  the  brief  warning,  that 
this  never  should  be  gauze,  as  it  does  not  drain.  Neither  do  I 
advise  glass  tubes,  as  I  have  seen  these  break  in  the  wound.  A 
rubber  tube  (Fig.  82),  if  used,  should  be  split  the  entire  length,  in 
order  that  fluid  may  run  into  it  at  any  point,  and  the  tube  itself 
be  withdrawn  more  easily,  than  one  with  holes,  into  which  granula- 
tions have  grown.  A  folded  rubber  dam  makes  an  excellent  drain, 
in  that  it  causes  no  pressure,  which  is  likely  to  result  in  decubitus. 
All  drains  should  be  sutured  to  the  edge  of  the  skin,  or  otherwise 
prevented  from  slipping  into  a  cavity  and  being  lost. 


Fig.  80. — The  insertion  of   stitches  which   are   intended  to   hold  gauze  packing  in  place. 


The  drain  opening  should,  of  course,  be  placed  at  the  most 
dependent  site.  It  is  well  to  remember  that  the  posture  of  the  pa- 
tient can  be  altered  to  influence  this.  For  instance,  we  frequently 
keep  a  patient  on  his  face  to  facilitate  abdominal  drainage. 
Chaput,17  for  some  time,  has  discarded  tubular  drainage,  in  path- 
ologic cavities  and  replaces  them  by  filiform  drains.  These  con- 
sist of  threads  of  varied  caliber.  The  drainage  is  capillary  and 
he  considers  this  form  of  material  much  heller  than  tubes,  and  says 
further,  that  they  permit  a  more  rapid  recovery  with  an  insig- 
nificant cicatrization.  T  distinctly  favor  through-and  through 
drainage  where  it  is  possible  to  secure  counter  openings.    The  ends 


TREATMENT    OF    WOUNDS 


429 


of  the   drain   are   fastened  together,    and   hence,   do   not    slip    out, 
thereby  insuring  greater  comfort  for  the  patient. 

Isuardi18  would  shatter  time  tried  tradition,  in  opposing  the 
employment  of  drainage  in  the  treatment  of  septic  wounds.  Of  two 
hundred  wounds  treated  by  him  in  the  Reserve  Hospital  of  Vercelli, 
thirty-two  were  very  grave  and  septic,  most  of  them  being  fracture 
wounds.  He  is  of  the  opinion  that  drainage  and  incisions  disturb 
the  progress  of  the  reparatory  process,  and  that  drains,  whether 
gauze,  rubber,  or  glass,  are  foreign  bodies,  which  irritate  the  tis- 


Fig.  81. — The  gauze  packing  held  in  place  by  tied  suture  ends. 

sues,  and  give  a  harboring  stronghold  and  breeding  place  to  mi- 
crobes. Isuardi  must  at  least  be  mentioned  for  the  sake  of  com- 
pleteness. 

Three  pregnant  statements  regarding  fixation  were  made  recently 
by  von  Eiselsberg,19  in  connection  with  the  treatment  of  emergency 
wounds.    They  relate  to: 

(a)  Fixation  of  bacteria  surrounding  the  wound,  and  the  protec- 
tive bandages. 


430  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

(b)  Fixation  of  broken  limbs  through  plaster  casts,  and 

(c)  Fixation  of  the  patient  on  his  bed. 

We  must  emphasize  the  advantages  of  titration  and  suspension 
as  applied  to  the  extremities.  They  favor  circulation,  and  hence 
minimize  edema,  relieve  pain,  and  altogether  hasten  repair. 

It  will  be  found  advisable  to  splint  an  extremity  on  which  there 
is  an  infected  wound.  The  patient  should  remain  as  quiet  as  pos- 
sible, since  motion  favors  spreading  of  infection  through  the 
lymphatics,  causes  pain  and  delays  healing.  The  dressing  can  be 
changed  through  a  fenestrum  (Fig.  83)  in  the  cast.  The  splint  is 
especially  advantageous  when  combined  with  elevation  or  suspen- 
sion. 

The  constant  exposure  of  granulations  to  a  blast  of  dry  air, 
preferably  warm,  is  said  by  Bergeat20  to  hasten  drying  up,  and  the 


Fig.  S2. — Split   rubber  tube  drain  as  used  at  the  Mayo  Clinic. 

whole  healing  process;  it  should  be  applied  for  five  or  ten  minutes 
at  a  time.  In  this  connection  a  hot  air  chamber  is  highly  recom- 
mended for  decreasing  edema,  and  promoting  shrinking  of  the  swol- 
len region;  ii  will  also  be  conducive  to  the  comfort  of  the  patient 
and  assisl   repair  through  improving  the  circulatory  conditions. 

Close  attention  musl  be  paid  that  granulations  art  not  lorn,  or 
caused  to  bleed  by  changing  of  gauze,  and  especial  care  should  be 
given  that  this  does  not  occur  at  the  edge  of  the  skin.  It  is  wise 
to  use  a  protection  of  gutta  percha  (Fig.  70);  this  renders  the 
dressing  painless  and  is  favorable  to  rapid  epidermization. 

Time  is  saved  in  the  healing  of  large  defects,  after  the  wound  is 
cleaned  up  and  granulations  are  healthy,  by  drawing  tht  shin  edges  to- 


TREATMENT    OF    WOUXDS 


431 


gether,  and  adhesive  plaster  will  be  found  most  convenient  in  this 
connection.  Strips  are  to  be  placed  a  short  distance  apart,  to  al- 
low the  escape  of  wound  fluids. 

Very  often  the  patient  complains  of  the  offensive  odor  of  the 
dressing.  The  sprinkling  of  two  or  three  drops  of  formalin  upon 
the  bandage  is  a  suggestion  which,  if  carried  out.  will  be  found  most 
efficient  in  overcoming  this  annoying  detail.  In  wounds  com- 
municating with  the  mouth,  a  packing  of  gauze  soaked  in  comp.  tr. 
of  benzoin,  which  may  remain  in  several  days,  will  completely  dis- 
pose of  the  characteristic  odor,  and  a  little  alcohol,  sprinkled  upon 
the  bed  clothes,  not  far  from  the  patient's  face,  is  an  effective  help 
in  disguising  disagreeable  smells. 

It  is  vastly  more  difficult  to  lay  down  rules  concerning  the  chang- 
ing of  dressings  on  infected,  than  on  clean  wounds.    Briefly,  we  may 


Fig.   S3.— Fenestrum  in  a  plaster  cast  as  used  at  the  Mayo  Clinic. 

say  that  every  instance  is  a  law  unto  itself,  and  the  amount  and 
character  of  the  excretions,  the  saturation  of  the  dressings  and  its 
odor,  the  sensations  of  the  patient,  as  well  as  the  temperature  chart, 
must  govern  the  surgeon. 

Foreign  Substances.— It  is  a  well-known  fact  that  the  healing 
process  in  wounds  is  delayed  by  the  presence  of  foreign  substances, 
an  example  of  which  is  seen  when  we  strangulate  a  mass  of  tissues 
with  a  ligature.  Among  the  many  illustrations  of  this  truth,  which 
present  themselves  to  mind,  is  a  case  in  which  a  bone  fragment  in 
an  infected  wound  causes  a  discharging  sinus;  the  wound  remains 
open,  refusing  to  heal,  until  the  removal  of  the  fragment,  after 
which   it   readily   responds   to   treatment.      In   another   instance,    a 


432 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


particle  of  clothing,  carried  in  by  a  projectile,  had  much  the  same 
effect.  Very  frequently  small  gauze  pads  have  been  left  in  wounds, 
causing  infection  and  sinus  formation,  which  necessitates  removal. 
Infected  nonabsorbable  ligatures  act  similarly,  and  we  may  men- 
tion that  drain  tubes,  which  are  not  fastened,  and  through  careless 
handling,  slip  in.  frequently  make  operative  removal  necessary. 

Some  Remote  Consequences  of  Wounds. — One  of  the  most  com- 
mon consequences  is  a  painful  scar.  as.  for  instance,  after  burns, 


Fig.   84. — Injecting  local  anesthetic   under  skin  of  thigh   previous  to  cutting  grafts. 

when  very  frequently  the  nerve  endings  arc  caught.  If  the  scar  is 
near  a  joint,  limitation  of  its  movements,  and  consequent  pain  is 
present.  Radical  breasl  operations  are  a  very  usual  cause  for  ihi* 
distressing  limitation  at  the  shoulder  joint.  The  best  prophylaxis 
is  early  movement.  Scars  are  very  frequently  most  disadvantageous 
about  the  hands  and  fingers,  in  that  the  resulting  limitation  of  mo- 
tion impairs  the  usefulness  of  the  member,  which  in  many  cases, 
decreases  tin1  earning  capacity  of  the  patient.     It  sometimes  occurs 


TREATMENT    OF    WOUNDS 


433 


that  a  large  nerve  is  caught  in  a  scar.  This  is  most  common  after 
fracture.  Very  recently  I  released  the  ulnar  nerve,  just  above  the 
elbow,  and  made  a  fat  sheath  for  it. 

Cancer  sometimes  forms  in  a  scar;  it  is  usually  in  an  old  one, 
and  is  most  frequently  met  with  in  elderly  people.  Quite  lately  I 
amputated  the  foot  of  an  elderly  gentleman,  for  cancer  under  the 
heel,  which  appeared  in  the  scar  of  a  burn,  received  thirteen  years 
previously.     At  the  present  writing,  I  have  under  treatment,   an 


Fig.  85. — Cutting  the  grafts  with  a  razor. 

old  lady  with  an  extensive  cancer  in  the  scar  of  a  varicose  ulcer, 
just  above  the  inner  aspect  of  the  ankle  joint. 

Late  Treatment  of  Wounds. — In  the  late  treatment  of  wounds, 
I  have  found  skin  grafting  (Figs.  84-93)  to  be  of  the  greatest 
value  in  hastening  the  repair  of  extensive  granulating  surfaces,  and 
am  in  favor  of  covering  the  defect  completely.  Sprengre21  ad- 
vises dividing  the  wound  by  two  or  more  skin-naps,  transversely 
across — one  from  each  side,  and  meeting  in  the  center,  if  necessary. 


434 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


TREATMENT    OF    WOUNDS 


435 


This  makes  at  least  two  new  wound  edges,  in  addition  to  those 
already  existing,  from  which  skin  formation  is  hastened  in  a  truly 
surprising  way  (Fig.  94).  It  is  advisable  to  wait  until  all  sloughs 
are  cleaned  off,  and  granulations  are  healthy. 

Ugly  disfiguring  scars  should  he  excised  and  the  defect  resutured, 
although  I  am  of  the  opinion  that  keloid  is  best  treated  by  radium 
or  x-ray. 

Depressed  scars  are  greatly  improved  in  appearance  by  a  hori- 
zontal subcutaneous  division,  and  the  insertion  of  fat  transplants. 
I  have  in  several  instances  rebuilt  a  complete  breast  in  this  manner, 
after  the  removal  of  all  but  the  skin,  for  benis'n  tumor. 


Fig.  88. — Grafts  in  place  on  a  varicose  ulcer 
of  the   ankle. 


Fig.   S9. — Cross  layers  of  gutta  percha,  which 
fix   grafts    and   their   backing   in   place. 


Transplantation  of  cartilage  successfully  corrects  a  depressed 
scar  over  ridge-like  eminences.  I  have  under  treatment,  as  this  is 
written,  a  boy  with  a  depressed  incisional  scar  across  the  bridge  of 
his  nose,  which  will  be  treated  by  subcutaneous  elevation,  and  in- 
sertion of  a  thin  section  from  a  costal  cartilage. 

The  transplantation  of  bone  (Fig.  95)  is  almost  too  common  at 
the  present  day,  to  merit  more  than  a  passing  mention,  nevertheless, 
it  is  possibly  not  so  often  done  for  cosmetic  purposes,  as  is  perhaps 
indicated.  "We  formerly -waited  to  get  a  clean  field,  but  Law2'2  has 
apparently  secured  as  effective  results  in  infected  areas  as  well. 
Autotransplantation  of  bone,  following  the  removal  for  carcinoma 


436 


AFTER-TREATMENT   OP    SURGICAL   PATIENTS 


Fig.  90. — Gauze  and  adhesive  which  covers  grafts  and  gutta  percha. 


Fig.  91. — Ordinary  gauze  bandage  which  covers  gauze  and  adhesive  left  on  forty-eight  hours. 


TREATMENT   OF    WOUNDS 


437 


Fig.  92. — Removing  gutta  percha  after  grafts  have  remained  in  place  forty-eight  hours. 


Fig.    93. — Open    air    treatment    of    grafts    after    first    forty-eight    hours'    compression. 


438 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


of  that  part  of  the  mandible  which  forms  the  chin  base,  was  re- 
cently accomplished  by  M^eKittrick.  The  region  in  which  the  grafl 
was  placed  was  infected  and  necessarily  remained  this  way  through- 
out the  time  the  wound  was  healing.  The  ultimate  outcome  resulted 
in  perfect  restoration  of  the  parts. 

It  is  hardly  necessary  to  mention  that  all  grafts,  no  matter  what 
tissue  is  involved,  must  he  taken  from  the  body  of  the  same  in- 
dividual, since  autografts  alone  can  be  depended  upon  to  remain 
viable. 


i  -kin. 


*W 


Pis- 
It  is  unfortunate  thai  lids  important  subjed  must   be  treated  in 
a    fragmentary   way.     A    large    monograph    would   be    required  if 
every  detail  of  it  were  to  be  exhaustively  considered. 


Bibliography 

iMarchand,  V. :     Der  Process  clei   Wundheilung,  Stuttgart,  verl.  v.  F.  Enke,  1901. 
-'Bier:      Byperaemie  als  Heilmittel,  F.  I  .   W.  Vogel,   Leipzig,   1903. 
Hilton,  John:     Rest  and  Pain,  NTew  York,  ls7'.'.  Maemillaii 
Ann.  Surg.,  1915,  Ixii. 


TREATMENT    OF    WOUNDS  439 

sSteuber:     Miinehen.  med.  Wchnsehr.,  1913,  xx,  1111. 
eZeuling:     Beitr.  z.  klin.  Chir.,  1913,  lxxii,  3. 
rBlumberg:     Inaug-Diss.,  Berlin,  Sept.,  1912. 
sGibson,  C.  L. :     Personal  communication. 
£>Lyle:     Jour.     Am.  Med.  Assn.,  Jan.,  1917,  p.  107. 
loDalton,  F.  J.  A.:     Brit.  Med.  Jour.,  1916,  i,  126. 
iiFraser,  J.:     Edinburgh  Med.  Jour.,  1916,  xvi,  127. 
12Medieal  Beseareh  Com. :     Lancet,  London,  1916,  cxc,  356. 
isOchsner,  E.  H. :     Tr.  So.  Surg.  Assn.,  1916. 
"Dves,  F.  G. :     Jour.  Am.  Med.  Assn.,  May,  1915. 
i-5Crile:     Surg.,  Gynec.  and  Obst.,  Oct.,  1916. 
isFisher,  H.  E. :     Jour.  Am.  Med.  Assn.,  1916,  Ixvi,  939. 
iTChaput,  H. :     Bull.  Soe.  de  Chir.,  1916,  xlii,  163. 
islsuardi:     Gior.  d.  v.  accad  di  med  di  Torino,  1915,  lxviii,  439. 
isvon  Eiselsberg:     Wien.  klin.  Wchnsehr.,  1913,  Xo.  23. 
20Bergeat:     Miinehen.  med.  Wchnsehr.,  1913,  xxy,  1377. 
siSprengre :     Deutseh.  Gesellsch.  f.  Chir.,  1901. 
22Law.  A.  A. :     Autografts  in  Infected  Fields. 

The  following  authorities  were  also  consulted : 
Bell,  John:     Discourse  on  the  Nature  and  Cure  of  Wounds,  Walpole,  X.  H.,  1807, 

Thomas  &  Thomas  &  Justin  Hinds,  i. 
Cheyne,  W.  W. :     The  Treatment  of  Wounds,  Ulcers,  and  Abscesses,  Philadelphia, 

1895,  Lea  Bros.  &  Co. 
Cheyne  and  Burghard:     A  Manual  of  Surgical  Treatment,  London  and  Bombay, 

1904,  Longmans,  Greene  &  Co.,  part  I. 
Gamgee,  S. :      On  the   Treatment   of  Wounds  and  Fractures,  Philadelphia,   1883, 

P.  Blakiston's  Son  &  Co. 
Hunter,  John:     A  Treatise  on  the  Blood,  Inflammation,  and   Gun-Shot  Wounds, 

Philadelphia,  1S23,  James  Webster. 
Pilcher,  L.  S. :     Treatment  of  Wounds,  New  York.  1S83,  Wm.  Wood  &  Co. 


CHAPTER  XL  IX 

BANDAGIN* ! 

By  0.  F.  McKittrick,  St.  Louis.  Mo. 

Bandages  play  an  important  role  in  the  care  of  the  postoperative 
patient.  Their  use  is  not  so  extensive  in  this  day  of  open  wound 
treatment  as  formerly,  but  they  are  still  found  indispensable  in 
holding  various  regional  "wound  dressings,  supporting  splints,  im- 
mobilizing points,  applying  pressure  for  arrest  of  hemorrhage, 
Bier's  hyperemia,  compression  of  varicosities,  and  many  other  con- 
ditions "which  arise  in  the  daily  routine  nursing  of  the  surgical  pa- 
tient. 

The  most  common  materials  utilized  for  this  purpose  are  usually 
bleached  or  unbleached  muslin,  crinolin,  or  this  latter  dress  lining 
to  which  sonic  hardening  substance  has  been  added  as  plaster  of 
Paris.  The  elastic  bandage  also  has  a  wide  range  of  usefulness. 
Ordinary  band  towels  are  employed  with  greal  effectiveness  by 
some  surgeons.  These  came  into  use  through  Mayo's  descrip- 
tion of  the  handkerchief  bandage,  and  -was  first  introduced  in  our 
work  by  Vilray  P.  Blair. 

Bandages  are  classified  as  simple  or  compound.  In  the  former 
the  materia]  is  in  one  piece,  as  exemplified  by  the  ordinary  roller 
bandage.  In  the  hitler  two  or  more  pieces  of  material  are  used, 
these  being  cui  to  suit  the  individual  portion  of  the  body  to  be 
covered.  The  crinolin  or  plaster  of  Paris  bandages  are  usually 
referred  to  as  immobilizing  bandages,  while  the  rubber  bandage  is 
considered  a  pressurt  bandage.  In  order  to  adequately  describe  the 
method  of  applying  the  bandage,  the  free  end  is  called  the  initial 
extremity  and  the  closed  end  is  known  as  the  terminal  extremity, 
the  portion  between  these  points  is  designated  as  the  body.  The 
surfaces  may  be  conveniently  designated  as  inner  and  outer,  re- 
spectively. 

In  describing  the  towel  bandage,  the  first  fold  made  preliminary 
to  applying  it  is  called  the  initial  fold,  while  the  sides,  ends,  and 
corners  of  the  towel  retain  their  original  names. 

Roller  muslin  bandages  are  most  conveniently  supplied  in  rolls 
of  five  to  ten  yards  long  and  are  the  full  width  of  the  muslin. 
This  is  usually  36  to  42  inches.     The  width  of  the  bandage  itself 

440 


BANDAGING 


441 


(1  to  6  inches)  is  regulated  by  cutting  them  off  the  main  roll  as 
shown  in  Fig.  96.  In  case  it  becomes  necessary  to  roll  a  bandage, 
machines  especially  manufactured  for  this  purpose  may  be  em- 
ployed, either  the  whole  width  of  the  muslin  is  encased  in  the  roll 
or  the  width  of  the  bandage  alone.  In  most  instances,  however, 
these  conveniences  are  not  within  reach,  and  the  bandage  is  rolled 
by  hand.  In  order  to  do  this  several  folds  are  made  into  a  small 
uniform  roll.  This  is  now  grasped  by  the  thumb  and  middle  finger 
of  the  right  hand  and  revolved  in  the  left  hand  so  as  to  force 
each  revolution  to  add  material  to  the  roll  from  the  strip  of  muslin 


Fig.  96. — Method  of  cutting  a  roll  of  muslin  into  bandages,  devised  by  Pattingson  of 
the    Mayo    Clinic. 

A.  Muslin,    36   inches   wide,    10  yards   long,   being   tightly   rolled   over   a   yard   stick   which 
is  pulled  out  at  the  end  of  the  roll  in  order  to  show. 
b.  Finished   roll,   yard   stick   partly   withdrawn. 

C.  Finished  rolls  ready  to   cut  into  bandages. 

D.  Cutting  the  bandages  into  desired  widths  in  a  miter  box.  This  box  is  made  of  pine. 
The  top  and  ends  are  left  open,  and  the  sides  are  sawed  so  as  to  permit  the  use  of  the 
Christy  knife.  The  bottom  is  divided  into  equal  parts  which  are  fastened  with  hinges. 
Four  foot  pieces  support  the  whole.  These  are  so  arranged  that  the  bottom  of  the  box  is 
beveled.  This,  together  with  the  three-cornered  pieces  of  wood  placed  on  each  side  at  the 
top  and  bottom  inside  the  box,  holds  the  bandages  absolutely  tight  as  pressure  is  placed 
on  them  during  the  cutting.  The  instrument  for  this  purpose  is  an  ordinary  Christy 
(bread)    knife. 

.E.  End  of  box  showing  the  bandage  held  securely  by  the  four  three-cornered  pine  strips 
within  the  box.  Note  the  beveled  bottom  of  the  box.  This  permits  pressure  as  desired 
during  the   cutting  process. 

F.  Bandage   box   open  with   cut  bandages   ready   for   removal. 

G.  The   finished  bandages. 


which  is  drawn  through  the  forefinger  and  middle  finger  of  the 
left  hand  as  shown  in  Fig.  97.  The  roll  can  then  be  wound  as  tightly 
as  desired  through  the  tension  exerted  by  the  fingers  of  the  left 
hand. 

Before  a  bandage  is  applied,  the  parts  to  be  covered  are  thor- 
oughly cleansed  with  water,  alcohol,  and  then  dusted  with  talcum 
powder.  If  a  wound  is  to  be  covered,  it  is  covered  first  with  gauze 
and  cotton  batting  or  sheet  wadding.    It  is  also  to  be  observed  that 


442 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


bony  prominences  are  to  be  treated  likewise,  and  occasionally  it  is 
desirable  to  have  all  the  parts  protected  with  this  material.  No  two 
skin  surfaces  are  to  be  allowed  to  come  in  contact,  cotton  or  sheet 
wadding  being  intervened. 

In  applying  the  roller  bandage,  the  body  is  contained  in  the 
right  hand,  the  initial  extremity  held  in  place  by  the  left,  and  the 
bandage  rolled  away  from  the  operator.  In  this  way  the  inner 
surface  becomes  the  center.  Wrinkles  in  the  cloth  are  to  be  avoided. 
The  edges  of  the  exposed  strips  of  bandage  are  turned  in  "while 
they  are  being  applied,  and  a  firm  smooth  application  of  the  band- 


Fig.  97. — Rolling  a  bandage  by   hand. 


Fig.    98. — Bandage 


age,  which  is  do1  too  tight,  is  the  objed  to  be  attained.  The  ex- 
tremities are  wrapped  from  the  distal  end  towards  the  body  of  the 
patient,  always  bearing  in  mind  the  danger  of  ischemia  with 
gangrene  from  too  great  or  uneven  pressure.  The  terminal  ex- 
tremity is  nicely  folded  to  a  point  and  fastened  with  adhesive  or  a 
safety  pin. 

In  removing  the  bandage  it  may  be  cut  with  bandage  scissors 
Pig.  Ms  or  unwrapped.  The  folds  are  kepi  massed  together,  which 
facilitates  the  transfer  of  the  unwrapped  bandage  from  one  hand 
to  the  other. 

A  concrete  description  of  the  various  kinds  of  bandages  em- 
ployed is  not  indicated  in  a  work  of  this  kind,  but  rather  in  one  in 
minor  surgery.  Still  there  are  a  few  points  which  should  be  dis- 
cussed and  to  these,  onlv,  will  attention  be  directed. 


BANDAGING  443 

Head  Bandages. — In  placing  the  frontooccipital  bandage  the  ini- 
tial extremity  of  a  roller  two  inches  wide  is  held  beneath  the  oc- 
cipital protuberance  and  the  body  is  then  carried  around  the  right 
side  of  the  head  across  the  forehead  and  then  around  the  left  side 
of  the  head  to  the  starting  point.  The  turns  are  repeated,  each  time 
a  part  of  the  preceding  turn  being  left  uncovered.  The  exposed 
edges  are  turned  in  as  shown  in  Fig.  99  and  the  terminal  extremity 
fastened  at  the  side  with  adhesive. 

In  covering  either  of  the  parietal  regions  alone  the  bandage  is 
fixed  as  in  the  bandage  above,  one  or  two  turns  being  made  so  as  to 
more  firmly  secure  it ;  then  beginning  at  the  occipital  protu- 
berance the  body  is  passed  obliquely  over  the  parietal  eminence  to 
the  forehead,  where  it  is  held  with  the  finger  directly  above  the 
eyebrow.     From  here  it  is  doubled  back  and  continued  to  the  oc- 


Fig.   99. — A  head   roller  bandage. 

cipital  protuberance  below  the  first  strip  of  bandage,  part  of  its 
external  surface  being  left  exposed.  The  bandage  is  now  brought 
back  to  the  region  of  the  eyebrow ;  this  time,  however,  the  body 
passes  above  the  first  layer.  The  body  is  continued  back  and  forth 
in  the  manner  described  until  the  region  is  covered.  Then  the 
bandage  is  secured  by  another  turn  or  two  around  the  head  as  in 
the  beginning.  All  edges  are  turned  under  as  the  folds  are  placed. 
The  terminal  extremity  is  fastened  at  the  side  with  a  strip  of 
adhesive. 

A  recurrent  bandage  is  commonly  employed  to  cover  the  entire 
vertex.  The  initial  extremity  of  a  roller  two  inches  wide  and 
six  yards  long  is  fastened  by  the  frontooccipital  turns  as  de- 
scribed above,  then  beginning  at  the  forehead  the  bandage  is 
doubled  on  itself  and  brought  directly  over  the  head  to  just  under 
the  occipital  protuberance,  making  a  right  angle  with  the  first  turns. 


444 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


From  here  it  returns  to  the  forehead  only  to  be  taken  back  to  the 
point  beneath  the  protuberance.  This  is  continued,  each  turn  cov- 
ering the  lower  portion  of  that  gone  before,  until  the  vertex  is 
completely  lost  to  view.  The  ends  of  the  folds  are  then  secured 
by  several  frontooccipital  folds  and  the  terminal  extremity  having 
been  nicely  brought  to  a  point,  is  held  in  place  with  adhesive. 

In  the  hands  of  some,  as  mentioned  above,  it  is  much  easier  to 
use  an  ordinary  towel  in  bandaging  this  region  of  the  body.     A 


Fig.    100. — A    towel    folded    for    bandaging. 


Fig.    101. — First   step   of  applying   towel    bandage   to    head. 

towel,  preferably  Kix'24  inches,  and  one  that  has  been  washed 
frequently  and  is  therefore  soft  and  easily  handled,  is  folded  as 
in  Fig.  100.  For  the  adult  head,  unless,  of  course,  too  much  dress- 
ing has  been  already  placed,  this  size  towel,  folded,  will  be 
found  most  satisfactory.  After  folding  the  towel,  the  center  of 
the  largest  surface  shown  in  the  figure  is  placed  directly  on  the 
back  of  the  head,  the  region  of  the  initial  fold  passing  under  the 


BANDAGING 


445 


occipital  protuberance.  The  ends  are  then  brought  across  the  sides 
of  the  head  above  the  ears,  and  fastened  at  the  root  of  the  nose 
as  in  Fig.  101.  Here  it  can  be  made  as  tight  as  desired  by  simply 
pulling  the  two  extremes  of  the  initial  fold  and  then  pinning  them 
in  place. 

The  corners  of  the  towel  now  protrude  as  seen  in  Fig.  101, 
one  having  been  simply  tucked  under  the  other.  The  opposite 
corner  is  at  once  brought  over  firmly  and  smoothly  and  fastened 
as  in  Fig.  102. 

If  it  is  unnecessary  to  include  the  eye  (or  eyes),  the  initial  fold 
of  the  towel  is  simply  brought  further  down  on  the  side  of  the  head, 
above  the  ears  and  fastened  over  the  bridge  of  the  nose.  In  this 
case  the  completing  folds  will  be  shorter  than  the  preceding  band- 


Fig.      102. — The     completed     head     bandage,        Fig.    103. — The  completed   head  bandage,   eye 
eyes    and    ears    (if    desired)     included.  (^r    eyes)     excluded. 

age  and  will  terminate  as  in  Fig.  103,  the  same  tucking  process  hav- 
ing been  carried  out  as  in  Fig.  102. 

In  bandaging  a  stump  the  recurrent  roller  bandage  (Fig.  104) 
may  be  applied.  It  is  placed,  in  the  main,  as  a  recurrent  bandage 
of  the  head,  and  need  not  be  further  described.  A  towel  is  easily 
utilized  here.  One  about  the  same  as  that  in  Fig.  100  is  folded  as 
there  depicted  and  the  initial  fold  is  fastened  around  the  extremity 
just  above  the  stump.  The  corners  are  then  tucked  in  and  pinned 
as  in  Fig.  101.  It  is  further  secured  by  adding  strips  of  adhesive 
plaster.  The  size  of  the  towel  depends  on  the  size  of  the  stump 
and  the  amount  of  dressings. 

If  such  bandages  are  applied  properly,  they  will  stay  on  in- 
definitely,   and    will   not   become    roughened    and    disarranged   so 


446 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


quickly  as  the  roller  bandage.  In  unruly  patients  or  the  delirious, 
it  may  become  necessary  to  attach  muslin  straps  behind  the  ears 
and  on  the  lower  edge  of  the  towel  so  that  they  can  be  tied  under 
the  chin  in  order  to  insure  against  the  slipping  of  the  bandage. 

When  one  eye  alone  is  to  be  included  in  the  head  bandage  the 
bandage  is  folded  as  in  Fig.  105,  and  applied  as  in  Fig.  101,  except 
that  the  side  of  the  head  and  the  adjacent  eye  are  covered  by  the 
initial  fold  of  the  towel.  The  corners  are  tucked  in  as  was  done 
in  Fig.  102.  The  final  appearance  of  the  bandage  is  shown  in  this 
figure. 

More  extensive  covering  of  the  head,  i.  e.,  one  which  includes 
the  cheek  as  well  as  the  eye.  usually  requires  a  larger  towel.  A 
size  16x28  inches  is  very  desirable.  11  is  folded  as  in  Fig.  105. 
One  cornei-  is  twisted  preparatory  to  placing  under  the  chin,  as  in 
Fig.  106.  The  initial  fold  of  the  towel  is  now  adjusted  around  the 
neck   and  then  pinned   to  the  twisted   corner.     This  gives  the  left 


Fig.    1114. — A  roller   bandage  applied 
tn   an  amputation   stump    (arm). 


Fig.   105.—  Method  of  folding  towel  for  band- 
aging   face. 


side,  the  one  requiring  the  bandage  in  the  first  place,  more  towel 
than  the  right,  as  depicted  in  the  figure.  The  latter  is  first  brought 
over  the  right  side  of  the  head  and  cranium,  and  being  tucked  in 
firmly,  is  at  once  covered  by  the  former  so  as  to  make  a  smooth, 
even  covering,  the  bandage  being  finished  as  in  Fig.  107.  The 
extent  of  the  face  covered  on  the  right  side  is  regulated  by  folding 
the  towel  to  the  desired  extent.  In  bandaging  the  left  side  of  the 
face  and  head,  the  towel  shown  in  Fig.  105  is  folded  so  as  to 
present  a  right  twisted  corner  instead  id'  the  left,  and  the  folds  made 
accordingly.  The  posterior  aspect  of  the  bandage  shown  in  Pig. 
ins  appears  in  Fig.   L09. 


BANDAGING  447 

Other  bandages  of  the  head  including  portions  beside  the  cranium 
and  excluding  the  towel  coverings,  are  explained  in  text  books  on 
Minor  Surgery.  One  of  these  which  proves  at  times  a  valuable 
dressing  is  the  Barton  bandage  or  some  modification  of  it.  In 
placing  this  bandage  the  initial  extremity  of  a  bandage,  two 
inches  wide  and  six  yards  long,  is  held  at  the  center  of  the  vertex, 
and  the  body  carried  over  the  left  parietal  bone,  under  the  oc- 
cipital protuberance  and  then  over  the  right  parietal  bone  to  the 
point  of  starting.  From  here  it  passes  over  the  left  temporal  bone 
in  front  of  the  ear,  along  the  side  of  the  face  to  the  chin,  under 
this,  then  up  the  right  side  of  the  face  and  head  to  the  starting 
point  again.  The  body  of  the  bandage  is  now  carried  over  the 
left  parietal  bone  again  to  the  point  under  the  occipital  pro- 
tuberance where  it  is  extended  around  the  right  base  of  the  skull 


Fig.     107. — Final    step    for    bandage    of    face 
Fig.    106. — First    step    of    face    bandage.  and    eye. 

along  the  right  inferior  maxilla  and  then  around  the  left  base 
of  the  skull  to  just  below  the  occipital  protuberance  where  it  then 
follows  the  former  strip  of  bandage  to  the  center  of  the  vertex. 
The  process  is  repeated  several  times  until  the  desired  number 
of  turns  are  made.  This  bandage  is  frequently  modified  by  adding 
a  frontooccipital  turn  before  any  of  the  turns  "are  repeated.  When 
this  has  been  accomplished  the  turns  are  followed  out  in  the  order 
named  above  until  the  bandage  is  completed,  the  intersections  being 
secured  by  means  of  adhesive  or  safety  pins,  care  having  been  taken 
that  all  edges  were  turned  under  during  the  application. 

For  the  many  other  bandages  of  the  head  the  reader  is  referred 
to  text  books  on  Minor  Surgery. 


448 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


Neck  Bandages. — One  of  the  simplest  bandages  of  the  neck  is 
that  shown  in  Fig.  110.  It  consists  simply  in  a  strip  of  gauze 
covering  the  dressing  over  the  wound  and  fastened  in  place  by  two 
strips  of  adhesive.  This  is  a  particularly  useful  dressing  for  goiter 
patients,  since  it  does  not  necessarily  encase  the  whole  neck.  It 
was  first  brought  to  my  attention  at  the  Mayo  Clinic. 

Another  simple  dressing  of  the  neck  is  that  shown  in  Fig.  111. 
A  roll  of  gauze  15  x  15  mesh  to  the  inch  is  placed  over  the  lesion  on 
the  neck,  which  in  this  case,  is  high  up,  reaching  nearly  to  the  lobe 
of  the  ear.  In  order  to  force  the  dressing  to  cover  the  lesion  without 
resorting  to  a  head  bandage,  a  piece  of  cardboard  or  several  layers 


Fig.    108. — Final    step    in    hood    bandage    for 
sidi  s    '>t'    face    ami    head. 


Fig. 


109.  —  Posterior     appearance      of      hood 
bandage. 


of  paper  are  eiil  ;is  in  the  figure  and  incorporated  in  the  dressing. 
The  idea  was  originated  and  carried  out  by  Frelich  at  the  Mayo 
Clinic. 

An  ordinary  unfolded  towel  may  lie  utilized  as  a  neck  bandage. 
It  is  placed  around  the  neck  and  over  the  wound  dressings  without 
any  preliminary  folding  and  pinned  as  in  Fig.  112.  The  small 
towel  as  shown  in  Fig.  100  fulfills  this  requirement  very  well. 

This  neck  covering  can  also  he  used  as  the  upper  part  of  a  breast 
bandage.  A  towel  long  enough  to  reach  around  the  patient  is 
folded  at  the  sides  and  then  passed  around  the  chest  and  pinned 
as  in  Fig.  114.  The  posterior  aspect  of  the  combined  bandage  is 
shown  in  Fig.  113. 

Probably  a  more  secure  bandage  and  one  meeting  the  same 
demands  is  that  shown  in  Pig.  108.  A  towel  just  large  enough  to 
fit  the  patient  comfortably  is  folded  in  its  Longest  dimensions  (Fig. 
115).      The    initial    fold   is    placed    directly    around    the    neck    and 


BANDAGING 


449 


held  in  position  with  a  safety  pin.  The  ends  of  the  towel  as  shown 
by  the  borders  in  Fig.  108  are  then  brought  around  the  shoulder 
under  the  arm  pits  and  pinned  at  the  back.  In  order  to  force  the 
bandage  to  remain  snugly  fit  in  front  and  also  keep  the  sides  of  the 
towel  in  place,  one  or  more  safety  pins  are  placed  as  shown. 

This  chest  bandage  is  used  in  connection  with  the  head  band- 
age as  shown  in  the  illustrations,  but  it  is  a  useful  bandage  ap- 
plied without  any  complicating  head  dressings,  and,  as  a  matter 
of  fact,  is  far  more  frequently  employed  separately. 


Fig.    110. — A   simple  dressing  with  gauze  support   for   goiters. 

In  bandaging  the  chest  alone,  a  simple  towel  folded  as  in  Fig. 
115  is  taken  by  its  farthest  corners  and  brought  around  the  body, 
the  initial  fold  of  the  towel  reaching  the  lowest  point  on  the  chest, 
while  the  ends  encircle  the  arms  as  in  Fig.  116,  and  are  pinned  at 
the  back  as  shown  in  Fig.  117.  The  pin  in  front  (Fig.  116)  merely 
holds  the  two  sides  of  the  towel  in  close  approximation.     Such  a 


450 


AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 


bandage  gives  freedom  to  the  arms,  is  easily  applied  and  is  com- 
fortable. 

Bandaging  the  shoulder  and  axilla  is  carried  out  by  taking  the 
towel  (Fig.  115)  by  its  extreme  corners  and  placing  it  on  the  shoul- 
der to  be  covered,  the  initial  fold  being  brought  nearest  the  base  of 
the  neck.  It  is  now  passed  around  the  body  to  the  opposite  axilla 
and  pinned  at  a  point  just  past  that  region  of  the  body.  The  initial 
fold  being  placed  highest  on  the  body,  the  sides  pass  around  the 
patient  at  the  lowest  extent  of  the  bandage,  the  ends  of  the  towel 


Fig.  111. — A  high  neck  bandage  held  up  by  cardboard  inserts. 

being  fixed  around  the  arm  and  pinned  at  the  axilla  to  be  band- 
aged (Figs.  118  and  119).  (In  this  case  it  is  the  right.)  A  gauze 
fold  may  be  placed  over  the  opposite  shoulder  to  hold  the  bandage 
more  securely. 

Fig.  120  shows  a  bandage  being  forced  to  fit  by  drawing  the 
initial  fold  taut  and  pinning  it  on  top  of  the  shoulder. 

Bandages  more  extensive  than  those  in  Figs.  108  and  109  are 
required  following  radical  breast  operations.  Usually  the  first 
bandage  applied  is  one  which  includes  the  arm  for  the  first  night. 
A  small  towel  unfolded,  is  laid  over  the  shoulder  so  that  its  ends 


BANDAGING 


451 


extend  beneath  a  larger  towel  which  covers  the  whole  of  the  arm 
(Fig.  120).  The  breast  wound  protected  with  gauze  and  a  sufficient 
amount  of  cotton  being  placed  under  the  arm,  this  extremity  is 
brought  over  onto  the  chest  and  the  end  of  the  towel  pinned  to  its 
fellow  of  the  opposite  side.  The  front  of  the  bandage  is  made 
straight  at  the  points  of  contact  by  tucking  in  the  lowest  part  of 
the  end  of  the  towel  (Fig.  120).  Safety  pins  are  put  at  desira- 
ble points,  one  supporting  the  hand  in  its  present  position.  Fig. 
121  shows  the  posterior  aspect  of  this  bandage.  The  pins  are  hold- 
ing in  position  the  towel  which  was  placed  over  the  uppermost  part 
of  the  shoulder. 

Fig.   113. 


Fig.   112.  Fig.   114. 

Fig.    112 — A  simple  neck  towel  bandage. 

Fig.   113. — Neck  and  breast  bandage  as  viewed  from  behind. 
Fig.    114. — A   combination   neck   and   breast   towei   bandage. 


A  bandage  which  only  partially  limits  the  arm  is  used  by  some 
at  this  early  stage.  In  these  cases  the  shoulder  bandage  as  shown  in 
Fig.  118  is  put  on  at  the  close  of  the  operation  and  the  circular 
towel  brought  around  the  arm  as  in  Fig.  120,  but  not  to  the  extent 
of  including  the  forearm.  The  two  surfaces  are  pinned  on  the  inner 
aspect  of  the  arm  as  they  meet  here,  after  encircling  it,  and  the 
end  now  passing  on  meets  its  fellow  of  the  opposite  side  and  the  two 
are  pinned  in  the  long  axis  of  the  body.  The  arm  is  partially  re- 
stricted further  by  placing  a  wide  strip  of  gauze  around  the  wrist 
and  pinning  this  to  the  towel  around  the  chest. 

The  following  day,  when  all  bleeding  has  stopped,  and  it  is 
desired  to  release  the  arm  from  the  bandage,  which  was  put  on  the 


452 


AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 


patient  while  still  on  the  operating  table,  this  is  removed  with- 
out disturbing  the  dressings  and  a  shoulder  bandage  as  depicted  in 
Fig.  118  is  placed  on  the  patient,  the  towel  being  forced  to  fit,  if 
necessary,  by  pinning  it  just  above  the  shoulder.  A  large  unfolded 
towel  is  now  brought  directly  around  the  body  close  up  under  the 
axilla  (Fig.  122)  and  pinned  in  front  parallel  with  the  long  axis 
of  the  body,  even  if  it  is  necessary  to  tuck  in  the  lower  part  of 
the  end  of  the  towel  to  accomplish  this  end.  The  shoulder  towel 
bandage,  and  the  circular  towel  bandage  are  further  fastened 
by  means  of  safety  pins  as  shown  in  Fig.  123.  Further  restraint 
being  unnecessary  the  gauze  cuff  (Fig.  124)  is  left  off  the  wrist. 
A  double-breasted   bandage  is  made  by  simply  adding  another 


Fig.    115 — The   towel   folded  as   vised   in   chest   handages. 


Fig.   116.— A   towel  chest  handagc.  Fig.    117.— Posterior   view   of   chest   bandage. 

towel  to  the  left  shoulder  as  in  Fig.  125.  or  else  placing  a  left 
shoulder  bandage  as  in  Fig.  118. 

If  it  is  necessary  to  have  the  arm  secured,  methods  resorted 
to  in  Figs.  120  or  121  are  easily  carried  out. 

Instances  requiring  still  more  fixation,  as  after  operations  for 
fractured  clavicle,  etc.,  where  the  towel  bandage  would  be  applied 
by  unskilled  hands,  ii  may  be  safer  to  use  the  well-known  Velpeau. 


BANDAGING 


453 


The  skin  is  first  thoroughly  cleansed  and  powdered  with  talcum, 
suitable  padding  placed  in  the  axilla  and  the  other  portions  of  the 
body  to  be  covered  are  protected  with  sheet  wadding.  The  arm  is 
acutely  flexed  (Fig.  126)  and  brought  across  the  chest  so  that  the 
palm  surface  of  the  hand  of  the  affected  side  rests  on  the  opposite 


Fig.   US. — Towel  chest  shoulder  bandage  held 
in   place   by    strip   of   gauze. 


Fig.    119, 


-Chest   shoulder   bandage   as   shown 
from   behind. 


Fig. 


120. — Chest    towel     bandage    with    arm 
included. 


Fig.    121. — Fig.    120    as   viewed    from   behind. 


shoulder  close  to  the  base  of  the  neck.  Two  or  more  bandages  2% 
inches  wide  will  be  required.  The  initial  end  of  a  roller  is  held 
over  the  body  of  the  scapula  of  the  sound  side.  The  body  of  the 
bandage  is  now  carried  over  the  unsound  shoulder  at  its  outer  part 
and  down  along  the  lateral  surface  of  the  arm  (Fig.  127),  under 
the  elbow  and  then  across  the  body  to  the  axilla  of  the  opposite 


454 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


side  to  the  beginning  point.  This  turn  is  repeated  once  or  twice 
in  order  to  thoroughly  anchor  the  bandage.  Starting  again  at  the 
scapular  region,  the  bandage  is  brought  directly  around  the  body 


Fig.   122.— A  double   towel  bandage  for  chest        Fig.     123. — Second     step    of    chest    shoulder 
and  shoulder.  bandage. 


Fig.  124. — Arm  held  in  position  by  ac- 
cessory fold  of  bandage  pinned  to  lower 
edge. 


Fig.    125. — Beginning   step  in   shoulder  breast 
bandage. 


across  the  point  of  the  elbow,  across  the  axilla  of  the  sound  side 
and  back  again  to  the  place  of  starting.  The  bandage  is  now  carried 
over  the   unsound   shoulder,   covering   the    inner   two-thirds   of   the 


BAXDAGIXG 


455 


strip  which  has  gone  before,  passes  behind  the  elbow  and  follows 
the  course  of  the  first  strips,  care  being  taken  to  cover  the  upper 


Fig.    126. — First  stage   of  Velpeau. 


Fig.    127. — Second   stage    of   Velpeau. 


Fig.    12S. — Third    stage    of    Velpeau. 


Fig.   129. — Fourth  stage  of  Velpeau. 


two-thirds  of  these  as  the  bandage  crosses  the  back  to  its  starting 
point  over  the  scapula.    The  process  is  now  repeated  until  the  arm 


456 


AFTER-TREATMENT    OP    SURGICAL    PATIENTS 


is  bound  securely  and  all  surfaces  covered,  the  bandage  traveling 
from  without  inwards  across  the  shoulder,  and  upwards  across  the 
arm  and  chest  (Figs.  128  and  129).  The  terminal  extremity  is 
fastened  with  adhesive  where  it  ends.  Other  strips  of  adhesive  are 
used  at  points  which  are  in  danger  of  slipping. 


Fig.    130. — A  convenient   towel   sling    for  arm. 


Pig.    131. — Gauze   sling    fur   arm. 


Fig.     132.     -Gauze    sling    supporting    wrist    of 
;   encased  in  plaster  of  Paris  dressing. 


Bandages  of  the  upper  extremity  may  be  composed  of  the  regular 
roller  or  common  towel.  In  utilizing  the  former  the  spica  of  the 
shoulder,  the  figure  of  eight  a1  the  elbow  or  the  spiral  reverse  for 
the  whole  arm  is  usually  employed. 


BANDAGING 


457 


Description  of  these  is  superfluous.  The  same,  however,  can  be 
accomplished  by  the  towel,  this  folded  and  applied  as  shown  in 
Fig.  130,  which  depicts  the  method  of  bandaging-  the  lower  ex- 
tremity is  also  used  here.  The  extent  of  the  surface  to  be  covered 
regulates  the  size  of  the  towel  and  the  length  of  the  initial  fold. 
A  larger  surface  requires  a  larger  towel,  and  the  length  of  the 
bandage  determines  the  amount  of  towel  turned  under.     Figs.  131 


Fig.   133. — The  sling  run  through  a  rubber  tube  to  protect  the  neck  from  pressure.     Forearm 
is   drawn   too   low  in   the   figure. 


and  132  depict  a  good  gauze  bandage  for  the  shoulder  and  arm 
(Mayo  Clinic),  while  Fig.  133  shows  how  the  neck  can  be  protected 
from  pressure. 

In  placing  a  towel  bandage  of  the  hand,  the  towel  should  be 
about  16  x  20  inches  and  folded  as  in  Fig.  134.  The  initial  fold 
is  brought  around  the  wrist  and  secured  with  a  safety  pin.     Then 


458 


AFTER-TREATMENT    OP    SURGICAL   PATIENTS 


the  side  of  the  towel  is  brought  under  the  thumb  and  the  edges 
tucked  nicely  over  the  dorsal  surface  of  the  hand  (Fig.  135)  the 
towel  then  read}'  to  complete  the  final  folds  is  straightened  out  as  in 
Fig.  135.     This  is  now  simply  wound  around  the  hand  and  pinned 


Fig.   134. — A   towel   folded   for  purpose  of  bandaging  hand.     First  step. 


Fig.    135. — Second   step    in    towel    bandage    of    hand. 


Fi£C. 


136. — Final    step    of    towel    bandage    of 
hand.      Palmer    aspect. 


Fig.    137. — Final    step    of    towel    bandage    of 
hand.      Dorsal    aspect. 


as  in  Fig.  136,  which  shows  the  dorsal  surface,  Avhile  Fig.  137  shows 
the  palmar  surface.     The  whole  procedure  resolves  itself  into  start 
ing  with  the  right  sized  towel  with  some  of  its  parts  folded  on  the 


BANDAGING 


459 


bias.  The  rest  is  a  matter  of  individual  folding  of  the  towel  so  as 
to  make  a  neat  appearance. 

Bandaging  the  fingers  is  best  done  with  the  roller  bandage, 
the  description  of  which  is  found  in  books  on  this  subject. 

Abdominal  bandaging  is  accomplished  by  the  abdominal  dressing 
and  binders  described  elsewhere  in  this  book. 


Fig.    138.— First    step    of    towel    bandage    of        Fig.    139.— Second   step   of  towel  bandage   of 
th'gh-  thigh. 


ud   thigh. 


Bandages  of  the  lower  extremities  are  usually  composed  of  the 
roller  as  for  the  arm.  Here  too  the  spica  of  the  groin,  knee,  ankle, 
and  foot  or  the  spiral  reverse  of  the  whole  lower  limb  need  not  be 
described.  Towels  taking  the  place  of  these  bandages  are  shown 
in  the  accompanying  figures.     Fig.  138  shows  a  towel  folded  pre- 


460 


AFTER-TREATMENT    OP    SURGICAL    PATIENTS 


paratory  to  covering  the  thigh.  The  initial  fold  is  first  anchored 
around  the  thigh  by  means  of  a  safety  pin  and  then  the  rest  of  the 
towel  is  simply  folded  around,  drawn  firmly  and  finally  completed 
as  in  Fig.  139.  A  roll  of  gauze  or  folded  towel  fixed  around  the 
waist  supports  the  upper  corner  of  the  towel  by  means  of  a  pin. 
For  more  extensive  covering  of  the  limb  a  larger  towel  is  secured 
and  the  initial  fold  is  made  much  shorter  than  in  Fig.  138.  In  this 
instance  it  is  first  placed  just  above  the  ankle,  the  towel  now  is 
simply  drawn  around  the  limb  and  pinned  as  in  Fig.  140.     A  band 


Fig.     141. — First    step    of    towel    bandage    of 
foot   and    ankle. 


Fig.    142. 


-Second    step   of   towel   bandage    of 
foot    and   ankle. 


Fig.    143  — Third    step    of    towel    bandage    of        Fig.     144. — Final    step    of    towel    bandage    of 
foot   and    ankle.  foot    and    ankle. 


of  gauze  pinned  to  the  waist  hand  keeps  it  firm  along  the  course 
of  the  extremity. 

In  bandaging  the  foot  the  towel  which  is  best  used  is  much  smaller 
than  the  one  employed  on  the  limb  above.  It  is  folded  as  in  Fig.  141, 
when  the  foot  is  placed  onto  it,  the  corner  nearest  the  heel  is  brought 
up  around  the  plantar  surface  of  the  foot.  The  end  of  the  towel 
is  now  pulled  tightly  over  the  dorsal  surface  and  tucked  in  on 
the  inner  side  (Fig.  142)  the  other  end  of  the  towel  is  folded 
over  the  toes  as  in  Fig.  143,  the  final  appearance  of  the  bandage 
being  something  like  that  in  Fig.  144.    Pins  are  placed  at  convenient 


BANDAGING 


461 


points  and  any  tucking  of  the  towel  necessary  to  make  a  firmer 
as  well  as  a  neater  appearance  to  the  dressing. 

T-bandages  are  very  useful.  They  are  either  single  (Fig.  145,) 
or  double  (Fig.  146),  and  are  used  mostly  for  holding  perineal 
dressings  in  place.  The  single  T-bandage  is  composed  of  two  strips 
of  unbleached  muslin  hemmed  and  sewed  together  in  the  form  of 
the  letter  "T."  The  top  strip  should  be  about  4x38  inches,  the 
other  strip  3  x  16  to  20  inches. 

The  double  T-bandage  is  made  the  same  way,  the  part  employed 
to  pass  around  the  body  has  the  same  dimensions  but  the  part  which 
passes  over  the  perineum  is  divided  in  the  middle  (Fig.  146).  This 
piece  is  the  same  length  as  in  the  single  "  T "  but  is  an  inch  or  more 
wider. 

A  T -binder  of  the  chest  is  a  very  handy  contrivance  at  times. 
It  is  composed  of  a  bandage  about  twelve  inches  in  width  and  long 


Fig.    1*5. — Single    T-bandage. 


Fig.    146. — Double-tailed    T-bandage. 


enough  to  pass  around  an  adult's  body.  The  strip  is  fastened  to 
its  upper  edge  so  as  to  pass  over  the  shoulder.  Another  strip 
passing  over  the  opposite  shoulder  is  sometimes  used.  The  strips 
are  pinned  in  front,  so  also  is  the  binder,  all  slack  being  taken  out 
by  mean  of  pins. 

Suspensory  bandages  are  extremely  necessary  after  operations 
involving  the  testes  or  any  part  of  the  anatomy  near  this  region 
as  well  as  the  groin. 

For  the  first  few  days  ordinary  adhesive  plaster  strapped  to  the 
sides  of  the  thighs  and  passing  directly  under  the  testes  may  be 
used.  Cotton  is  placed  directly  under  the  testes  so  as  to  avoid 
possible  irritation  and  give  a  still  better  support.     (Fig.  62.) 


462  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

Aii  ordinary  piece  of  gauze  brought  around  the  testes  and  held 
with  adhesive  alone  makes  a  quite  efficient  suspensory  so  long 
as  the  patient  remains  in  lied. 

Adhesive  placed  directly  on  the  scrotum  and  then  fastened  to  the 
abdominal  wall  is  sometimes  employed.  The  scrotum,  unless  shaved, 
will  give  more  or  less  pain  due  to  the  hair  which  will  be  pulled  by 
the  adhesive.  It  holds  the  scrotum  well  up  and  prevents  edema,  but 
on  account  of  the  fault  mentioned  is  not  a  comfortable  suspensory. 

By  far  the  best  apparatus  for  this  purpose  is  one  consisting  of 
a  web  body  which  supports  the  testes  and  at  the  same  time  is 
itself  held  in  place  by  a  small  waist  band  and  perineal  straps. 
This  suspensory  is  besl    used   late   in  the   course   of  the  recovery 

sii a  better  fit  can  be  obtained  at  this  time  as  the  edema  will  have 

disappeared  from  the  scrotum  and  unnecessary  irritation  and  pres- 
sure from  the  straps  are  avoided  at  a  time  when  the  tissues  are 
most  susceptible  to  injury.  The  surgeon  should  (il  these  suspen- 
sories, as  one  too  tight  will  cause  trauma  and  swelling,  while  one 
too  large  is  of  little  value. 

The  most  important  immobilizing  dressing  is  the  plaster  of  Paris 
bandage.  Fixation  bandages  have  been  in  use  many  centuries,  a 
mixture  of  other  material,  such  as  chalk,  mussel  shells,  albumen,  oil, 
hemp,  etc.,  having  been  utilized  in  their  manufacture.  It  was  not 
until  the  middle  of  the  nineteenth  century  however,  that  the  plaster 
of  Paris  bandage,  which  now  holds  the  Eoremosl  place  in  this  kind 
id'  dressings,  came  into  common  use. 

The  bandage,  as  ordinarily  employed,  is  bought  ready  made 
from  the  stores,  and  so  often  does  not  fulfill  the  expectations  of  the 
operator.  This  is  due  to  many  causes.  In  the  first  place,  it  may  con- 
tain too  much  calcium  carbonate,  which  prevents  complete  harden- 
ing of  the  plaster,  when  mixed  with  water.  The  plaster  may  have 
absorbed  too  much  water,  due  to  exposure  to  the  atmosphere,  or  in 
drying  out  such  plaster,  it  may  have  become  too  hot.  and  thereby 
rendered  it  almosl  useless,  since  it  then  takes  up  water  poorly. 
The  plaster  may  have  been  shaken  from  the  meshes  of  the  crinolin 
by  too  severe  handling  in  shipping,  etc. 

The  most  satisfactory  bandage  is  one  made  of  crinolin  (25x25 
meshes  to  the  inch  and  the  best  grade  of  dental  impression  plaster, 
smoothly  and  uniformly  filling  the  meshes  throughout  the  band- 
age. Such  bandages  are  conveniently  made  by  buying  crinolin 
by  the  bolt.  Each  bolt  contains  twelve  yards,  folded  in  half-yard 
lengths.     The  boll    is  cut  at  the  sixth  fold,   which   exactly  divides 


BANDAGING 


463 


it,  leaving  therefore  six  yards  to  the  piece.  Each  piece  of  crinolin 
is  now  rolled  on  a  yard  stick  (Fig.  96,  page  441),  and  put  away 
for  a  week  or  more  until  the  former  creases  have  disappeared  from 
it;  at  the  end  of  this  time  the  roll  is  placed  into  a  miter  box,  and 
cut  with  a  Christy  knife,  into  widths  the  size  of  the  required  band- 
age. The  miter  box  (Fig.  96),  as  employed  by  Pattingson,  who 
prepares  all  the  bandages  used  at  the  Mayo  Clinic,  is  beveled 
at  the  bottom,  so  that  pressure  from  the  top  forces  absolute  fixa- 
tion of  the  crinolin,  during  the  cutting,  which  naturally  insures 
a  more  uniform  roll.  As  employed  at  this  clinic,  the  rolls  are 
4  and   6   inches,   respectively,   though   any   size  roll   may   be    cut. 


Fig.   147. — Pattingson's  plaster  bandage   rolling  machine  used  at  Mayo   Clinic.      (Viewed   from 

the   side.) 


Fig.    148. — Pattingson's  plaster  bandage   rolling  machine  used  at  Mayo   Clinic,      (Viewed   from 

above.) 

The  crinolin  roll  is  first  "squared"  at  the  end,  then  as  the  band- 
ages are  cut,  the  frayed  edges  are  carefully  freed  of  the  threads, 
which  immediately  form  the  side  of  the  bandage.  This  precaution 
prevents  the  hands  of  the  operator  becoming  entangled  in  a  useless 
mass  of  threads,  as  he  attempts  to  apply  the  dressing. 

The  plaster  of  Paris  is  next  added  to  the  bandage.  This  can 
be  done  either  by  hand,  or  by  using  some  instrument  especially  made 
for  this  purpose.  O-ne  of  the  best  which  I  have  had  occasion  to 
observe  is  that  employed  by  Pattingson  (Figs.  147  and  148).  He 
does  not  permit  us  to  give  this  instrument  in  detail,  but  in  the 
main  it  consists  of  a  rectangular  tin-lined  wooden  box,  so  arranged 


464 


AFTER-TRKATMKXT    OF    SURGICAL    PATIENTS 


that  the  crinolin  is  drawn  from  a  spindle  at  one  end  of  the  box, 
through  the  plaster  to  the  spindle  at  the  other  end.  The  proper 
proportion  of  plaster  deposit  is  automatically  regulated  by  a 
sliding  gate  in  the  middle  of  the  box,  -which  is  accurately  set  and 
held  in  place  by  a  side  pin  so  that  it  arranges  that  the  meshes  are 
exactly  and  uniformly  filled  with  the  plaster.  A  metal  weight  at- 
tached to  a  curved  tin  which  supports  the  roll  forces  the  bandage 
to  be  rolled  at  the  proper  tightness  This  latter  is  very  important, 
since  a  bandage  too  tightly  rolled  does  not  absorb  the  water  readily, 
and  one  too  loosely  rolled  does  not  retain  the  plaster. 

A  small  metal  pan.  which  catches  the  excess  of  plaster  as  the 
bandage  revolves,  is  retained  at  the  end  of  the  box.  The  spindles 
are  so  arranged  that  by  moving  a  special  board,  any  sized  bandage 
can  be  rolled. 


Fig.   149. — Pattii  plaster  of   Paris  bandages  in  tissue  paper 

1.  r>andap:c  placed  to  the  right  of  tin-  middle  of  the  tissue  paper. 

2.  Beginning  the   roll. 

3.  Turning  in  tin-  side. 

4.  Showing   in   detail   method   of  turning  in   the   side. 
:*  Ad\  an<  ed  in    the   side. 

Almost   completed — crumpling   in   the   end. 
7.   Compli  ' 

When  the  bandage  is  completed,  it  is  removed,  and  rolled  firmly 
backward  and  forward  under  the  edge  of  the  hand,  which  doubly 
insures  uniform  distribution  of  the  plaster.  The  terminal  extremity 
of  the  bandage,  having  been  encased  in  the  plaster,  is  pinned  to 
the  body  of  the  bandage. 

When  bandages  are  rolled  by  hand,  the  crinolin  bandage  is 
dragged  over  a  heap  id'  plaster  of  Paris  as  wide  or  wider  than  the 
width  of  it  and  as  the  roll  of  the  plaster  bandage  is  begun,  plaster 


BANDAGING 


465 


is  sprinkled  on  the  upper,  exposed  portion  of  the  crinolin,  in  order 
to  equally  thoroughly  impregnate  it  as  the  lower  side  is  already  well 
covered  by  its  contact  with  the  plaster  lying  under  it.  The  roll  is 
made  loose  and  even,  the  process  being  best  carried  out  on  some 
hard  surface  at  the  foot  of  the  heap  of  plaster. 

In  order  to  prevent  the  bandage  from  absorbing  moisture  from 
the  atmosphere,  and  thereby  rendering  it  useless,  Pattingson  rolls 


Fig.   ISO. — A  device  for  immersing  plaster  of  Paris  bandages. 

the  bandage  in  a  good  grade  of  tissue  paper  as  in  Fig.  149.  The 
paper  which  surrounds  the  bandage  is  so  arranged  that  only  one 
end  remains  open,  to  be  closed  later,  by  a  twist  of  the  paper.  The 
completed  bandage  then  is  placed  in  a  tin  box  in  a  dry  place  and 
kept  in  readiness  for  immediate  use. 


4fi6 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


The  paper  is  held  in  place  by  a  small  rubber  band  around  the 
roll.  The  wrapped  bandages  are  now  stored  in  tightly  covered 
tin  boxes,  located  in  some  dry  place,  where  they  are  kept  ready 
for  use.  As  soon  as  they  are  required,  the  number  necessary  for 
completing  the  dressing  is  brought  out,  and  placed  near  the  bucket 
of  water  in  which  they  are  to  be  immersed. 

In  wetting  the  bandage,  preparatory  to  its  immediate  use,  we 
do  not  remove  the  paper,  but  tear  away  the  ends,  so  as  to  allow 
free  access  of  water  and  at  the  same  time  allow  no  plaster  to  es- 
cape. The  bandage  is  immersed  slowly,  and  is  then  held  beneath  the 
surface  until  all  bubbles  have  ceased  to  appear,  and  the  original 
hard  roll  is  soft  and  pliable.     It  is  now  taken  from  the  liquid,  and 


Fig.    151.      A   device   for  expressing  water   from   plaster   of   Paris   bandages. 


the  excess  gently  squeezed  out,  by  compressing  with  a  hand  holding 
each  end  of  the  bandage.  The  paper  is  at  once  removed,  and  the 
bandage  is  then  ready  for  use. 

Henderson,  at  the  Mayo  Clinic  employs  a  readymade  wire  stage 
(Fig.  150)  supported  by  a  long  rod  which  he  uses  to  immerse  his 
bandages.  This  is  a  convenient  contrivance,  when  a  large  amount 
of  such  work  is  required,  bu1  ordinarily  the  hand  alone  is  sufficient 
for  this  purpose,  or  a  potato-masher  may  be  employed  as  is  done 
at  Rochester  (Fig.  151). 

Regardless  of  the  method,  however,  immersion  should  be  so  timed 


BANDAGING 


467 


that  a  bandage  is  kept  ready  for  instant  use,  so  as  not  to  delay  the 
operator. 

The  water  which  is  usually  employed  is  warm,  and  without  the 
addition  of  salt,  alum,  sugar,  etc.  In  cheaper  grades  of  plaster, 
such  chemical  adjuvants  are  found  useful  in  bringing  about  quicker 
setting,  but  with  the  high  grade  dental  impression  plaster,  this  is 
unnecessary. 

When  the  floor,  table,  and  surroundings,  have  been  adequately 
protected  by  newspapers,  the  patient  is  placed  in  position,  the  skin 
powdered,  and  the  tricot  applied.  .  After  the  bony  prominences  have 
been  protected  with  heavy  felt  or  cotton,  the  plaster  is  then  applied. 
Care  must  be  taken  not  to  use  too  much  padding,  as  this,  at  times, 
interferes  with  the  firm  support  of  the  bandage. 

Unfortunately,  this  dressing  is  most  often  required  in  patients 
who   are  bedridden.     It  is  always  a  matter  of  more   or  less  im- 


Fig.   152. — A   convenient  box   for  supporting  patient   during  application   of  plaster   cast. 


portance,  as  to  what  method  is  best  pursued  in  getting  the  patient 
in  position  for  the  application  of  this  important  dressing.  In  cases 
requiring  a  spica  of  the  thigh,  including  a  dressing  also  for  the 
body  and  limb,  I  have  found  the  following  procedure  a  very  good 
one :  the  patient  is  taken  from  his  bed  and  wheeled  to  the  operating 
room,  where  he  is  placed  upon  the  operating  table.  When  proper 
precautions  have  been  taken  so  that  he  does  not  become  chilled, 
he  is  brought  well  down,  so  that  his  lower  limbs  extend  off  the 
table,  and  are  supported  by  an  assistant.    A  homemade  plaster  box 


468 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


is  placed  under  the  body.     Further  support  than  this  is  deemed  su- 
perfluous. 

The   plaster  box.   which   is   the   secret   of   good   support   in   such 
eases,  and  one  which  we  employ,  was  devised  by  Blair.     It  is  simply 


l:ig     153. — Apply    tricot    and    felt    as    preliminaries    to    plaster    cast. 


Fig.    154. — Applying    plaster   cast   with    reinforcement   of   iron   strips. 

a  wooden  box  made  of  timber  V/2  inches  thick.  It  is  24  inches  long, 
20  inches  wide,  contains  no  sides  or  lop.  but  the  end  pieces  are  8 
inches  high.    On  the  surface  of  the  end  pieces,  and  near  the  center, 


BANDAGING  469 

are  located  two  iron  supports  for  the  two  iron  strips  (Fig.  152)  which 
bear  the  weight  of  the  patient.  The  iron  strips  are  2  inches  wide, 
%  inch  thick,  and  are  malleable,  so  that  they  can  be  bent  to  fit  the 
curve  of  the  patient's  back.  The  box  as  usually  employed  is  shown 
in  Fig.  154  though  in  some  cases  it  can  be  turned  over  as  in  Fig. 
153  and  a  metal  support  given  the  hips.  I  have  found  this  last 
method  not  nearly  so  efficient  as  using  the  box  alone. 

In  cases  requiring  a  cast  of  the  leg  only,  this  may  be  supported 
by  strips  of  muslin  bandaging,  which  are  attached  to  iron  piping, 
located  directly  over  this  bed  and  patient.  It  is  held  in  place  by 
two  wooden  supports,  strapped  to  the  bed.  When  the  cast  has  been 
made,  the  muslin  is  cut,  and  the  defect  closed  by  a  few  turns  of  the 
bandage.  This  method  is  very  efficacious  in  handling  large  patients, 
when  one  is  short  of  help.  It  is  not  so  convenient  when  the  hip  and 
body  are  to  be  encased  in  the  cast.  However,  with  the  plaster  box 
placed  under  the  patient,  this  procedure  could  be  carried  out,  even 
in  bed,  though  not  nearly  so  efficiently  as  when  the  patient  is  taken 
to  the  operating  table. 

The  skin,  previously  thoroughly  cleaned,  is  now  sprinkled  with 
talcum  powder,  and  then  covered  with  seamless  tricot  hose.  This 
elastic  material  can  be  secured  in  any  width  desired,  and  can  be 
stretched  to  snugly  fit  any  portion  of  the  body.  When  it  is  neces- 
sary to  cut  the  tricot  here  and  there,  to  perfect  the  fit.  the  several 
parts  are  held  with  adhesive.  Heavy  felt  is  now  placed  across  the 
abdomen  at  the  highest  point  reached  by  the  plaster,  and  another, 
extending  over  the  anterior  superior  spines  of  the  ilii.  Others  are 
placed  over  the  trochanters,  the  knee,  around  the  heel  and  ball  of 
the  foot,  as  in  Fig.  153.  Directly  under  the  top  in  front  a  pillow, 
roll  or  other  filling  may  be  used  to  prevent  too  tight  application  of 
the  bandage  in  this  region,  which  would  embarrass  respiration,  and 
cause  gastric  discomfort.  The  pillow  roll  is  removed  at  the  close 
of  the  procedure. 

The  operators  are  protected  with  gown  and  rubber  gloves.  The 
plaster  bandage,  as  described  above,  is  taken  and  rolled  firmly,  but 
not  tightly,  over  the  areas  to  be  c-OATered.  The  bandage  is  not  al- 
lowed to  wrinkle,  and  each  layer  is  so  placed  that  it  lies  flat,  Ee- 
versing  the  bandage  is  unnecessary.  The  plaster  is  kept  smooth  by 
frequent  rolling  with  the  hand  throughout  its  application.  In  ap- 
plying the  bandage  as  shown  in  Fig.  155,  it  will  be  necessary  to 
give  the  same  amount  of  weight  to  the  hip  opposite  to  that  covered 
with  the  bandage,  or  else  the  patient  will  slip  off  the  box.  This  is 
accomplished  by  holding  it  down  with  the  hand  and  at  the  same 


470 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


time  the  limb  is  held  parallel  with  the  affected  one  which  is  ab- 
ducted and  slightly  bent,  depending  on  the  condition  for  which 
operation  was  performed. 

As  the  application  of  the  bandage  proceeds,  supports  are  placed 
at  the  sites  most  likely  to  break  with  muscular  movements.     This 


1 55. — Usi 


the   healthy   thigh. 


Fig.    156. — Removing   iron   supports   from   the   plaster  hox. 

is  accomplished  by  means  of  heavy  wire,  wood,  or  iron  strips,  bent 
to  suit  the  individual  u 1.  In  addition,  further  support  by  fold- 
ing the  bandage  on  itself,  ;is  in  Pig.  154  and  then  placing  it  at  tin1 
desired  points,  is  very  efficacious.     Pig.  L54  shows  a  strip  already  in 


BANDAGING 


471 


place  posteriorly,  in  addition  to  the  iron  strip  and  another  fold  of 
plaster  being  prepared  for  use  elsewhere.  As  the  bandage  nears 
completion,  the  tricot,  which  is  purposely  left  long,  (Fig.  153)  is 
turned  back  over  the  plaster  and  secured  by  additional  folds  (Fig. 
155).  The  completed  bandage  is  light,  well  supported  with  strips 
of  bandage  and  iron  bars,  also  the  skin  protected  along  all  edges 


Fig.    157. — A   fenestrum   for   dressing  the  wound. 

by  layers  of  felt  or  cotton,  which  is  covered  with  tricot,  as  shown 
in  Fig.  155.  The  trimming  of  the  bandage  takes  place  on  the 
table  while  the  plaster  is  drying  and  is  still  soft,  and  before  the 
tricot  is  turned  over  the  edges.  Otherwise  this  procedure  is  post- 
poned until  the  patient  is  off  the  operating  table,  and  the  cast  is 
dry:  then  upon  wetting  the  part  to  be  trimmed  with  plain  warm 


472  AFTER-TREAT.UEXT    OF    SURGICAL   PATIENTS 

water  or  water  in  which  a  little  acid  (acetic)  has  been  added,  the 
cast  can  be  easily  cut  with  a  sharp  knife.  The  tricot  is  then  pulled 
over  the  cut  edges  and  fastened  with  adhesive,  running  length- 
wise with  the  turns  of  bandage. 

The  iron  bars  of  the  plaster  box  which  supported  the  patient  on 
the  table  are  removed  as  shown  in  Fig.  156  just  as  soon  as  the  cast 
becomes  hard  enough  to  keep  from  breaking  when  these  are  taken 
out. 

Fenestra,  as  shown  in  Fig.  157,  are  made  after  the  east  becomes 
hardened.  The  plaster  cut  from  these  areas  is  strapped  with  ad- 
hesive, and  held  in  place.  Casts  cut  to  relieve  tension,  are  also 
strapped  with  adhesive  plaster  to  hold  the  parts  together. 

In  applying  the  initial  layers  of  a  plaster  of  Paris  bandage, 
the  same  rules  as  regards  any  bandage  (concerning  the  prevention 
of  esehemia,  venous  stasis,  etc.  I  must  be  observed.  In  addition,  the 
pressure  from  this  unyielding  covering  is  apt  to  produce  necrosis, 
gangrene,  etc..  so  that  the  bony  prominences  can  hardly  be  too 
critically  watched.  Any  pain  complained  of  must  be  carefully 
looked  into,  and  extra  fenestra  cut  if  necessary  to  relieve  the  pres- 
sure and  pain.  Neither  the  toes  nor  the  lingers  should  be  incased 
in  such  bandages,  and  when  an  extremity  is  so  fixed,  most  careful 
attention  must  be  given  these  digits,  as  cyanosis  and  coolness  are 
the  first  indications  of  the  bandage  being  too  tight.  The  position 
which  the  patient  will  maintain  in  the  cast  is  assumed  at  the  be- 
ginning of  the  application,  and  he  is  held  in  place  by  competent 
assistants.  Failure  to  rigidly  enforce  this  rule  often  causes  the 
bandage  to  be  applied  incorrectly,  which  is  followed  by  breaks  and 
discomfiture  to  the  patient,  necessitating  a  reapplication  of  the 
dressing. 

A  description  of  the  various  kinds  of  plaster  bandages,  and  the 
indications  for  their  use,  is  no1  deemed  proper  in  a  work  of  this 
kind,  but  I  should  like  to  call  attention  to  the  low  hip  immobilizing* 
cast,  which  is  sometimes  employed  in  old  people. 

A  high  dressing  tightly  binding  them  around  the  upper  abdomen 
can  not.  at  times,  be  tolerated,  and  in  such  cases  it  is  necessary  not 
only  for  the  comfort  of  the  patient,  but  also  for  his  actual  safety, 
that  such  means  of  treatment  are  not  insisted  upon.  In  these  cases, 
where  such  measures  are  necessary,  a  low  cast  is  applied,  one  which 
extends  to  just  below  the  umbilicus,  and  above  the  knee.  The  casl 
is  made  as  described  above,  but  is  firmly  supported  by  one  wire 
around  the  waist,  and  outer  side  of  the  leg.  and  one  wire,  bent   so 


BAXDAGIXG  473 

as  to  follow  the  curve,  at  the  lower  portion  of  the  cast,  and  extend- 
ing on  the  inner  side  of  the  thigh.  The  wire  is  incased  in  the  folds  of 
plaster  so  as  to  avoid  injuring  the  patient  or  pushing  through  the 
bandage  on  the  outside. 

Another  bandage  is  that  employed  by  Henderson  for  immobilizing 


Fig.  158. — A  plaster  cast  split  for  temporary  removal. 

the  arm  and  shoulder  after  transplantation  of  bone  for  ununited 
fractures  of  the  arm.  The  cast  is  applied  before  the  operation,  with 
the  patient  in  the  standing  posture,  which  insures  its  perfect  fit 
and  avoids  the  usual  dangers  attendant  upon  such  dressings.  The 
bandage  is  shown  in  Fig.  158.  A  temporary  dressing  is  put  on  the 
arm  to  be  operated,  the  same  size  that  is  to  be  used  following  the 


474  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

operation.  The  cast  is  made  over  all,  and  is  allowed  to  stay  in 
place  until  it  hardens.  Then  the  plaster  is  v\-et  along  the  line  of  in- 
cision, and  the  cast  cut  through,  dividing  it  into  two  equal  halves, 
and  is  removed,  as  shown  in  Fig.  158.  A  fenestrum  is  cut  over  the 
operation  site  and  held  in  place  by  adhesive.  Immediately  after  the 
operation,  and  as  soon  as  the  wound  is  dressed,  the  two  halves  of 
this  cast  are  placed  around  the  patient,  and  held  together  with 
strips  of  adhesive,  as  in  Pig.  158.  Such  a  dressing  permits  the  pa- 
tient to  be  up  and  around  very  soon  after  the  operation,  without 
the  slightest  danger  of  displacing  any  bony  fragments  from  move- 
ments of  the  arm. 

The  dressing  is  light,  durable,  and  covers  a  small  portion  of 
The  chest  only,  which  prevents  any  interference  with  respiratory 
movements.  The  fenestrum  permits  change  of  dressing  whenever 
desired.  If.  for  any  reason,  discharge  issues  from  the  wound  em- 
braced in  the  cast,  the  edges  of  the  fenestra  are  covered  with  col- 
lodion, which  prevents  moistening,  and  therefore  softening  of  the 
cast,  which  would  soon  defeat  the  purpose  for  which  it  was  orig- 
inally intended. 

The  drying  of  the  cast  is  accomplished  by  simply  keeping  it 
uncovered.  As  soon  as  the  patient  returns  from  the  operating  room. 
measures  are  taken  to  carry  out  this  procedure.  If  it  does  not  then 
dry  fast,  an  electric  fan  is  turned  on  it.  or  hot  bags  of  salt  placed 
around  it.  which  drives  away  the  moisture. 

In  removing  the  cast,  the  patient  need  not  leave  his  bed;  this 
is  protected  by  rubber  sheeting,  and  the  floor  with  papers.  Along 
the  line  of  incision,  cotton  strips,  soaked  in  plain  hot   water,  or  hoi 

water   to   which    vinegar   has    1 n    added    are   applied,   and    as   soon 

as  there  is  a  line  of  softening,  the  casl  is  divided  along  its  course 
with  a  sharp  knife,  particular  care  being  exercised  that  the  patient 
is  not  injured  by  the  knife.  The  underlying  tricot,  cotton,  etc., 
arc  cut  with  a  pair  of  bandage  scissors,  as  shown  in   Pig.  98. 

Bibliography 

Sister  Constance:     St.  Anthony's   Hospital,  St.  Louis,   Personal  communication. 

Pattingson:     Personal  communication. 

Blair,  A*.  P.:      Personal  communication. 

Henderson :     Personal  communication. 

Henderson:     Ann.  Surg.,  April,  lOlfi. 

Ware:     Plaster  of  Paris  and  How  to  Use  It.  1906. 

Fowler:     The  Operating  Room  and  the  Patient,  1913. 


CHAPTER  L 

THE  ABDOMINAL  BINDER 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

The  role  which  abdominal  supports  play  in  the  surgical  con- 
valescent has  always  been  an  uncertain  one.  The  tendency  among 
most  operators  is  to  discard  them  altogether,  a  practice  which  can 
never  meet  with  universal  approval,  since  there  are  certain  classes 
of  patients  whose  physical  needs  demand  their  use.  Like  all  ques- 
tions involving  human  infirmities,  one  rule  will  not  apply  to  every 
individual,  and  the  indiscriminate  application  of  an  unyielding 
idea,  renders  it  unsafe.  However,  it  is  generally  observed  that  the 
first  few  days'  treatment  of  the  incised  abdominal  wall  is  approx- 
imately the  same  among  the  majority  of  operators,  and  the  va- 
riance of  opinion  concerning  this  subject  is.  in  the  main,  directed 
toward  the  later  protection  to  be  given  it. 

Immediately  following  the  completion  of  the  sewing  necessary 
to  close  the  abdominal  wound,  gauze  (20x20  mesh  to  the  inch) 
is  placed  over  it,  either  flat  or  fluffed,  the  amount  to  be  determined 
according  to  whether  or  not  the  wound  is  drained.  A  layer  of  cotton 
batting,  or  a  pad  made  of  cotton  batting,  and  covered  with  gauze, 
is  placed  over  the  flat  gauze,  which  covers  the  wound ;  the  pad 
is  now  strapped  with  2  inch  adhesive,  and  the  patient  placed  in  bed. 
This  dressing  is  popular  in  many  of  the  large  clinics.  The  adhesive, 
however,  gives  considerable  support,  if  used  in  4  inch  strips,  and 
applied  well  around  the  body  on  both  sides.  There  is  some  danger 
of  such  binders  coming  off.  thereby  exposing  the  wound  to  infec- 
tion; otherwise  they  are  inexpensive,  easy  of  application,  do  not 
restrict  respiration,  or  any  of  the  body  movements,  and  being  light 
and  cool,  are  especially  comfortable  in  summer. 

It  has  long  been  a  practice  in  hospitals  throughout  the  country, 
however,  to  apply  a  cotton  domestic  binder,  as  in  Fig.  159  in  ad- 
dition to  the  previously  mentioned  dressing,  and  in  many  cases, 
the  dressing  without  the  adhesive  straps.  The  binder  is  first 
pinned  tightly  up  the  front,  and  the  slack  at  the  sides  is  then 
taken  up  by  using  the  pins,  as  in  the  illustration.  I  feel  that,  in 
many  cases  at  least,  such  extra  precautions  could  be  easily  dispensed 
with,   especially  in  those   cases  which   do   not  fall  into   the   class 

475 


476 


AFTER-TREATMENT    OP    SURGICAL    PATIENTS 


of  individuals  to  be  suggested  as  favorable  candidates  for  such 
treatment.  The  support  which  the  additional  covering  adds  to  the 
properly  applied  adhesive,  is  not  sufficient,  so  long  as  the  patient 
remains  in  bed,  to  warrant  the  unnecessary  discomfort  which  it 
sometimes  entails.  Some  hospitals  employ  perineal  straps  to  pre- 
vent the  binder  from  slipping  upward,  and  thus  exposing  the  wound; 
these  straps  at  times  give  no  end  of  annoyance. 

In  clean  wounds,  the  dressings  are  not  disturbed,  except  to  make 
sure  the  wound  is  healing  normally,  until  the  stitches  are  to  be 
removed.  In  drained  wounds  other  measures  must  be  employed, 
in  order  to  allow  frequent  dressings.  In  such  cases  the  usual 
dressings  are  employed,  but  the  adhesive  is  drawn  tightly  over  the 
pad  by  means  of  gauze  strings,  and  tied.  The  adhesive  is  then 
placed  well  under  the  back,  usually  three  strips  three  inches  wide, 
and  so  arranged  as  to  pull  evenly  with  the  strip  on  the  opposite 


Fig.    159. — The    ordinary    immediate   abdominal    binder    pinned    on    in    the    operating    room. 

side.  In  placing  the  gauze  string,  care  is  taken  that  the  strip  is 
made  long  enough  to  come  up  well  over  the  dressing,  and  in  line 
with  the  one  on  the  opposite  side.  The  two  parts  of  the  adhesive 
are  stuck  together,  so  thai  the  free  end  extends  below  the  lower  por- 
tion of  the  pad.  which  prevents  its  sticking  to  the  dressing.  The 
wound  with  such  a  covering  can  be  dressed  frequently  without  dis- 
turbing the  patient,  and  at  the  same  time,  gives  good  support  to 
the  abdominal  wall. 

The  abdomen  receives  no  further  protection,  so  lonij-  as  the  stitches 
are  in  place,  and  the  patient  remains  in  bed.  As  soon  as  the  stitches 
are  removed,  usually  within  ten  days,  in  wounds  healing  by  first 
intention,  more  attention  must  be  accorded  the  abdominal  wall. 
This,  however,  is  not  urgent  until  the  patient  is  allowed  to  sit  up. 
Crossen1  as  a  matter  of  routine,  applies  boric  acid  powder  to  the 
wound   and   then,   having   placed   a    Hat   piece   of  gauze   over  it,  he 


THE   ABDOMINAL   BINDER  477 

applies  an  adhesive  binder  to  the  lower  abdomen,  which  gives  ample 
support  to  the  healing  wall.  The  strips  of  adhesive  which  form 
the  support  are  two  inches  wide  and  are  smoothly  applied  with 
moderate  tension,  from  below  extending  upward.  This  maneuver 
prevents  unnecessary  wrinkles  in  the  binder,  and  tends  to  push  the 
abdominal  contents  upward.  Such  a  procedure  takes  all  strain 
from  the  abdominal  wound  and  insures  against  its  rupture,  either 
in  whole  or  in  part,  during  any  sudden  increase  in  intraabdominal 
pressure.  Over  the  adhesive  is  placed  a  pad  of  cotton  batting ;  this 
in  turn  is  held  with  the  binder.  The  adhesive  support  is  worn  for 
about  one  month,  a  straight  front  corset  having,  in  the  meantime, 
been  adjusted  over  the  dressing,  worn  during  the  daytime,  and  re- 
moved at  night.  If,  for  any  reason,  the  wound  is  to  be  inspected, 
the  portion  covering  it  can  be  removed,  and  the  abdomen  re- 
strapped. 

The  rules  which  we  observe  in  applying  an  adhesive  support  are 
those  outlined  by  Soper2  in  the  use  of  his  abdominal  support  for 
gastroptosis.  These,  in  the  main,  imply  that  the  first  strips  applied, 
i.e.,  the  "X"  strips,  are  first  anchored  to  the  dorsal  vertebra,  and 
then  directed  so  as  to  follow  the  lower  margin  of  the  ribs.  The 
patient,  being  in  the  sitting  posture  when  this  maneuver  is  accom- 
plished, now  lies  flat  on  the  back.  The  abdominal  contents  are 
pushed  up,  and  the  strips  continued  across  the  abdomen,  one  at  a 
time,  to  be  attached  at  the  sides  in  the  region  of  the  inguinal  liga- 
ments. The  cross  strips  are  now  placed,  beginning  at  the  anterior 
superior  spines  of  the  ilii.  In  patients  whose  operations  did  not  re- 
quire an  abdominal  incision,  i.e.,  those  in  whom  all  work  was  ac- 
complished through  the  vagina,  the  Soper  support,  which  is  a  modi- 
fication of  that  devised  by  Eose,  can  be  worn  without  the  additional 
coverings  as  employed  in  laparotomies.  Such  a  support  is  not  bur- 
densome to  the  patient,  and  it  does  not  interfere  with  the  routine 
habits  of  life.  If  the  skin  becomes  irritated,  the  dressing  is  removed 
with  a  little  benzine  and  after  a  few  days  is  reapplied. 

Except  the  dressing  and  possibly  the  additional  binder,  no  further 
abdominal  support  is  required  during  the  two  or  three  w^eeks  the 
normal  individual  is  recuperating  from  the  operation. 

As  for  the  general  use  of  abdominal  binders,  Mills3  says  there  is 
no  particular  indication  for  them,  but  when  they  are  brought  into 
service  they  should  be  used  selectively,  for  instance,  in  people  with 
lax  abdominal  walls,  due  to  great  loss  of  weight,  frequent  child 
bearing,  large  abdominal  tumors,  such  as  the  fibromata,  multilocular 


478  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

cysts,  etc.,  and  especially  in  patients  with  very  much  fat  or  pen- 
dulous abdomens. 

Occupations  such  as  laborers  who  do  heavy  lifting  or  those  who 
lead  sedentary  lives  may  require  the  utilization  of  abdominal 
binders. 

Static  conditions  play  a  part  in  deciding  when  to  use  the  abdom- 
inal support.  Patients  with  round  shoulders  always  have  poorly 
developed  abdominal  Avails,  since  the  entire  burden  of  standing  is 
thrown  upon  the  muscles  of  the  back;  the  abdominal  muscles  being 
so  little  used,  accounts  for  the  lack  of  development  of  the  abdominal 
wall. 

The  type  of  the  individual  must  be  considered.  Those  generally 
debilitated,  or  who  are  naturally  of  poor  physique,  especially  re- 
quire this  treatment.  Such  patients  lack  general  tone,  and  as  a  result 
there  is  a  state  of  generally  diminished  tone  in  the  abdominal  muscles. 
Many  women  of  frail  asthenic  physique  have  naturally  a  low  di- 
gestive plane,  and  in  such  the  viscera  are  abnormally  low.  How- 
ever, the  low  position  of  the  viscera  per  se  in  individuals  not  en- 
titled to  such  visceral  topography,  is  an  indication  for  the  binder. 

Patients  with  the  " enteroptotic  habitus"  of  Mills  are  frequently 
operated  upon.  But  there  are  other  cases  of  gastroptosis  or  gen- 
eral visceral  ptosis  that  are  also  seen  here,  and  in  such  patients, 
especially,  must  attention  be  given  to  the  artificial  support  of  the 
abdomen.  Normally,  their  peritoneal  attachments  of  the  viscera 
are  slack,  the  organs  being  kept  in  position  by  the  positive  intra- 
abdominal pressure.  This  is  maintained  by  the  tonus  of  the  ab- 
dominal and  pelvic  musculature.  Any  decrease  in  tone  in  these 
muscles  produces  a  weakness  which  permits  an  increase  in  the  ab- 
dominal cavity,  and  causes  a  decrease  in  the  intraabdominal  pres- 
sure, with  a  resulting  pull  on  the  peritoneal  attachments  followed 
by  a  fall  of  the  viscera.  Hertz4  states  that  a  decrease  in  the  bulk  of 
the  abdominal  contents,  such  as  a  diminution  in  the  normal  intra- 
abdominal fat,  will  also  bring  about  the  same  result  as  the  decrease 
in  muscular  tone,  and  general  laxity  of  the  muscles.  At  any  rate. 
the  conditions  usually  go  hand  in  hand,  and  as  Mills  has  said,  the 
accumulation  of  a  desirable  amount  of  intraabdominal  fat  is  greatly 
to  be  desired  in  these  cases,  where  marked  loss  in  nutrition  as  a 
result  of  the  surgical  condition  is  present. 

The  character  of  the  wound  is  vitally  important  in  deciding  upon 
the  use  of  a  support.  The  muscle  splitting  incision  of  McBurney. 
very  rarely  requires  support.     Usually  such   wounds  are   covered 


THE    ABDOMINAL   BINDER 


479 


with  a  collodion  dressing,  or  supported  with  adhesive  strips,  and 
the  patient  allowed  up  in  two  or  three  days.  The  anatomic  relations 
are  not  disturbed,  and  consequently  there  is  very  little  danger  of 
hernia.  The  rectus  incisions  when  properly  performed,  require  very 
little  more  attention  than  the  McBurney  incision. 

Incision  through  the  linaa  alba,  below  the  umbilicus  requires 
greater  support  than  the  muscle  incisions  above.  Here  the  pressure 
exerted  on  the  abdominal  wall  is  greater,  and  the  wound  does  not 
receive  the  benefit  of  any  muscular  support.  Wounds,  however, 
made  above  the  umbilicus,  whether  within  this  region  or  through 
the  abdominal  muscles,  rarely  require  any  support  at  all. 


Fig.  160. — An  ordinary  straight  corset. 
Front  view.  (Courtesy  Just-Us  Corset  Co., 
St.   Eouis.) 


Fig.     161. — Ordinary    straight    corset, 
view. 


Back- 


Wounds  which  have  been  drained,  and  therefore  heal  by  second 
intention,  require  longer  and  more  intelligent  care,  than  those  which 
heal  by  first  intention.  Just  how  long  binders  should  be  worn  in 
such  cases  depends  entirely  upon  the  type  of  individual,  the  length 
of  time  in  bed,  and  the  nature  and  size  of  the  defect.  In  no  instance 
does  a  wound  demand  a  longer  time  than  six  months  after  the  skin 
has  closed  over  it  to  heal  soundly.     Binders  should  not  be  worn 


480 


AFTER-TREATMENT    OF    SURGICAL   PATIENTS 


longer  than  this  period,  except,  possibly  in  the  very  obese.  In  such 
cases,  some  sort  of  abdominal  support  will  be  necessary  to  be  worn 
throughout  the  life  of  the  patient. 

Cases  properly  handled  surgically  as  to  direction  of  incision,  ac- 
curate dissection,  with  perfect  approximation,  and  cleanliness 
usually  need  no  artificial  support.  No  binder  should  take  the  place 
of  a  well-developed  abdominal  wall,  but  is  applied  to  relieve  the 

tension  present  on  the  wound.  This  tends 
not  only  to  prevent  a  wide,  thin  scar, 
but  also  to  some  extenl  prevents  hernia. 
It  is  usually  worn,  in  those  cases  which 
need  it,  until  the  wound  has  thoroughly 
healed.  This  is  ordinarily  about  four 
weeks,  but  Longer  periods  of  time  are 
sometimes  required  depending,  of  course, 
upon  the  nature  of  the  case.  But  in  no 
instance  should  il  be  worn  longer  than 
six  months,  except  in  the  condition  as 
noted   in   the    foregoing. 

Abdominal  binders  acl  as  splints  to  the 
musculature,  and  too  long  continuance 
will  produce  atrophy  from  disuse.  How- 
ever, within  the  Limits  of  time  suggested, 
the  support,  that  is.  the  weight  of  the 
viscera  being  Lifted  from  the  abdominal 
wall,  allows  the  overstretched  muscles  to 
regain  their  tone,  and  the  comfort  secured 
from  such  devices  allows  the  patient  many 
times  to  eat  more  without  fear  of  dis- 
comfort, and  take  more  exercise.  This 
not  only  tends  to  overcome  the  sluggish- 
ness of  the  intestines,  hut  also  1o  increase  the  amount  of  intraab- 
dominal  fat. 

The  binder  is  hut  a  makeshift,  in  that  it  protects,  and  by  protect- 
ing renders  possible  an  opportunity  for  the  development  of  the  ab- 
dominal Avail,  through  exercises.  These  are  begun  just  as  soon  as 
the  wound  is  thoroughly  healed.  The  abdominal  exercises  are  first 
started  moderately,  allowing  Hie  patient  to  raise  her  body  from  the 
Hat  position  to  the  sitting  posture  without  raising  the  heels  from 
the  floor.  This  is  impossible  for  some  patients  to  accomplish  at 
first,  but  after  many  trials,  these  same   persons  carry  out  the  pro- 


Fig.   162.      Tin-  athlc  lie  web 
coi  set.     Side  view. 


THE    ABDOMINAL    BINDER 


481 


cedure  with  ease.  It  should,  never  be  persisted  in  sufficiently  to  tire 
the  patient ;  however,  the  feat  can  be  performed  several  times  a  day, 
each  day  increasing  the  number  of  times  the  process  is  repeated. 
Further  abdominal  exercises  should  be  followed  out  as  suggested 
by  Posse,5  but  for  the  first  six  months  the  abdomen  should  be  pro- 
tected during  the  exercise,  by  some  abdominal  pad  or  adhesive 
binder. 

Many  contrivances  have  been  presented  for  use  as  late  abdominal 
supports.     I  have  found  very  little  use  for  any  of  them.     The  most 


Fig. 


163. — The    athletic    web    corset, 
view. 


Front        Fig. 


164. — The     athletic     web     corset     laced. 
Front    view. 


important  feature  to  be  observed  in  selecting  a  support,  is  that  it 
applies  itself  to  the  lowest  segment  of  the  abdomen,  and  in  so  doing, 
fits  closely  to  the  inguinal  ligaments,  as  near  as  possible  to  the 
symphysis  pubis,  and  does  not  quite  reach  to  the  umbilicus.  The 
abdominal  contents  are  thereby  pushed  upwards,  backwards,  and 
inwards,  which  alone  efficiently  relieves  the  muscular  strain.  The 
apparatus  should  be  as  plain  as  possible,  inexpensive,  and  at  no 
time  cause  any  discomfort  to  the  patient. 


482  AFTER-TREATMENT    OP    SURGICAL    PATIENTS 

In  my  experience  I  have  found  no  support  to  surpass  the  ad- 
hesive strips  further  reinforced  by  the  straight  front  corset  (Figs. 
160  and  161),  when  the  patient  is  out  in  the  world  again,  and  per- 
forming the  duties  of  life.  Some  patients  find  great  comfort  in  the 
athletic  corset,  which  is  composed  mostly  of  rubber  web  (Figs.  162 
and  163).  Such  corsets  can  be  worn  indefinitely,  without  any  injury 
to  the  abdominal  wound,  so  long  as  the  lower  abdomen  is  pushed 
up  while  the  corset  is  being  laced  from  the  bottom,  and  the  ab- 
dominal exercises  kept  up.  For  cases  with  pendulous  abdomens, 
the  very  obese,  or  the  visceroptotic,  I  have  found  that  best  results 
can  be  obtained  by  having  the  patient  fitted  with  a  corset  most 
suited  to  her  build  and  size.  In  such  corsets  some  insert  a  rubber 
web  support,  which  is  attached  to  the  corset.  The  added  elastic 
support  fulfills  every  requirement,  and  yet  the  patient  is  not  con- 
scious of  the  necessity  of  wearing  an  abdominal  binder  for  her 
condition.  The  belt  is  so  adjusted  that  it  unhooks  as  does  the 
corset,  and  very  little  trouble  is  thereby  entailed.  This  insures 
its  more  frequent  use  by  the  patient.  At  night  no  support  is  worn, 
the  corset  being  utilized  during  the  time  the  patient  is  on  her  feet 
only. 

In  men,  the  adhesive  support  of  Soper  has  proved  amply  suffi- 
cient. 

All  cases  requiring  the  use  of  abdominal  supports  should  see  the 
surgeon  occasionally,  to  make  sure  that  the  supports  are  carrying 
out  the  purpose  for  which  they  were  intended. 

Bibliography 

iCrossen:     Operative  Gynecology,  St.  Louis,  L915,  C.  V.  Mosby  Co.,  p.  602. 

sSoper:     Jour.  Mo.  State  Med.  Assn.,  January,   L912. 

sMills,  R.  Walter:     Personal  communication. 

*Hertz:     Pract.  Enclyp.  Med.  Treat,,  Till."),  323. 

sPosse:     Special  Kinesiology  of  Educational  Gymnastics,  p.  168. 


CHAPTER  LI 

EXERCISE  AND  MASSAGE 
By  F.  H.  Ewerhardt,  St.  Louis,  Mo. 

In  the  consideration  of  the  after-treatment  of  operative  cases 
it  seems  timely  to  incorporate  in  the  plan  physical  measures,  which, 
if  properly  applied,  will  stimulate  repaired  processes.  Such 
agencies  as  massage,  remedial  exercises  and  hydrotherapy  will  here 
receive  thought  and  attention.  These  measures  have,  until  lately, 
received  very  little  consideration  at  the  hands  of  the  medical 
profession;  little  or  no  thought  was  given  them  by  the  medical 
school  curriculum.  Consequently  most  surgeons  have  but  a  passing 
knowledge  of  its  technic,  physiologic  effect  or  therapeutic  applica- 
tion. Scientific  research  and  clinical  experience  have,  however, 
placed  it  on  a  rational  basis.  Massage  has  gained  recognition  as  a 
result  of  the  labors  of  Lucas  Championneire  of  France,  who  was  the 
first  to  champion  massage  and  manipulation  in  the  treatment  of 
fractures;  Sir  Wm.  Bennett  of  England,  Mezter  of  Amsterdam, 
Zabludowski  of  Berlin,  Peter  H.  Ling  of  Sweden  and  later  Graham, 
Weir  Mitchel  and  W.  K.  Mitchel,  Jacob  Bolin,  Kellogg  and  others 
of  America.  Among  the  pioneers  in  modern  hydrotherapy  the  fore- 
most was  Winternitz  of  Germany  who  was  followed  by  Brandt, 
Ziemssen,  Schott  and  Fleury  in  Europe,  and  Kellogg,  Pope,  Pratt, 
Baruch  and  others  in  America.  In  the  field  of  medical  gymnastics 
we  turn  first  to  Sweden,  where  Peter  H.  Ling  founded  his  well- 
known  system  of  Swedish  gymnastics.  Others  to  follow  him  were 
Enebuske,  Nissen,  Wiede,  Kleen,  Jahn  and  Kellgreen  of  Europe  and 
Nils  Posse,  Jacob  Bolin,  McKenzie,  Bucholz  and  others  in  the 
United  States.  Due  to  the  labors  of  these  men  physical  therapy 
has  been  incorporated  in  the  medical  curriculum  of  all  the  im- 
portant European  universities  and  is  practiced  extensively  in  most 
of  the  large  hospitals  in  the  United  States. 

This  work  has  received  a  tremendous  impetus  during  the  past 
great  war  and  is  being  employed  intensively  in  German,  English 
and  French  convalescent  hospitals.  It  is  not  the  purpose  _at  this 
time  to  go  into  a  comprehensive  description  of  massage,  exercise 
and  baths,  but  rather  to  present  an  outline  of  those  measures  in  a 
brief  fashion,  and  yet  embrace  the  salient  elements  in  a  manner 

483 


484  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

which  may  be  of  best  service  to  the  busy  surgeon.  The  mode  of 
presentation  will  embrace  the  technic,  the  physical  effect,  and  the 
indications. 

Massage 

General  Discussion. — The  question  who  should  apply  massage  is, 
of  course,  a  very  pertinent  one.  Theoretically  this  should  be  the 
physician  himself.  His  technical  knowledge  of  anatomy  and  physi- 
ology coupled  with  the  intimate  understanding  of  the  patient's 
physical  condition  and  idiosyncrasies  places  him  in  a  most  favorable 
position  for  the  performance  of  this  work.  Practically,  however, 
this  is  not  true  because  of  the  time-consuming  element  involved. 
Neither  the  general  practitioner  nor  the  specialist  finds  it  a  judicious 
division  of  labor  to  devote  a  great  part  of  his  time  to  massage  and 
other  forms  of  physical  therapy,  and  it  is  well  for  the  future  of 
these  measures  that  it  is  so,  for  otherwise  it  would  not  have  reached 
its  present  high  development.  Massage,  for  instance,  covers  such 
a  big  field  that  men  and  women  spend  months  of  training  in  theory 
and  practice  in  order  that  they  may  reach  a  degree  of  perfection 
commensurate  with  medical  requirements.  They  are  required  to 
master  to  a  fair  degree  a  knowledge  of  physiology  and  anatomy  and 
in  addition  possess  a  fair  understanding  of  the  pathology  of  dis- 
eases. The  physician's  part  in  the  matter  of  massage  is  to  possess 
a  good  working  knowledge  of  its  technic  and  its  therapeutic  ap- 
plication. It  would  be  wise  for  him  to  have  in  addition  a  fair 
degree  of  skill  so  that  he  himself  could,  if  necessary,  perform  the 
work,  particularly  in  localized  areas,  when  the  labor  involved 
would  cover  only  a  short  period  of  time.  In  order  to  meet  these 
indications,  namely,  to  give  the  busy  surgeon  an  opportunity  of  be- 
coming acquainted  with  this  subjecl  and  be  able  to  intelligently 
prescribe  and  perform  the  work  himself  if  necessary,  a  brief  de- 
scription devoid  of  exhausting  details  and  repetitions  follows: 

Fundamentally,  success  following  massage  depends  largely  upon 
proper  technic  based  on  a  knowledge  of  anatomy  and  physiology. 
A  few  general  remarks,  however,  relating  in  some  way  or  other  to 
the  subject  are  perhaps  not  amiss.  Apparently  trifling  elements 
are  oftentimes  of  sufficient  importance  to  make  or  mar  the  success 
of  the  whole.  Preferably  the  operator  should  be  of  genial  and 
sympathetic  disposition,  yet  firm  in  the  correct  performance  of  his 
work.  He  should  exercise  cleanliness  with  respect  to  himself  as 
well  as  to  the  material  with  which  he  works.  The  surroundings 
should  be  quiet  and  inviting.     It  is  quite  discomforting  to  be  mas- 


EXERCISE   AND    MASSAGE  485 

saged  by  an  unkempt  individual  in  an  untidy,  dark  room.  The 
operator,  if  not  a  doctor,  should  be  extremely  careful  in  discussing 
the  patient's  condition,  treatment  or  prognosis.  Patients  are  fre- 
quently prone  to  question  the  operator  along  these  lines,  which  often- 
times results  in  embarrassing  situations.  The  operator  must  ever 
remember  his  relation  to  the  doctor;  viz.,  to  adhere  closely  to  in- 
structions, avoid  discussing  the  treatment  with  the  patient,  and 
never  offer  advice. 

Authorities  agree  that  barring  certain  conditions,  massage  should 
be  performed  on  the  bare  skin.  Bucholz  of  the  Massachusetts 
General  Hospital  makes  this  exception:  "In  cases  of  a  septic  hand 
where  some  granulations  or  superficial  sinuses  still  exist,  and  where 
delay  until  these  openings  are  all  healed  would  cause  adhesions  and 
scars  to  become  still  firmer  and  stronger,  kneading  and  friction 
may  be  done  with  benefit  through  a  sterile  sponge."  Or,  he  adds, 
"in  the  case  of  a  sprained  ankle  strapped  with  adhesive  plaster." 

It  is  always  essential  to  keep  in  mind  the  healthy  condition  of 
the  skin.  If  the  stroking  movements  are  to  predominate,  some 
lubricating  material  should  be  employed  to  prevent  irritation  of 
the  hair  follicles.  For  this  purpose  any  of  the  following  may  be 
used:  Cold  cream,  white  vaseline,  cottonseed,  olive,  cocoanut  or 
mineral  oil;  or  cocoa  butter.  If,  however,  deep  kneading  or  fric- 
tion is  primarily  indicated,  a  too  thorough  lubrication  of  the  skin 
would  interfere  with  the  proper  performances  of  the  movements. 
The  operator  will  then  find  it  very  difficult  to  properly  grasp  the 
deeper  structures.  In  these  cases  common  talcum  powder  had  bet- 
ter be  used  or  nothing  at  all.  Again,  parts  that  need  to  be  mas- 
saged more  than  two  or  three  times  should  not  be  shaved.  If  there 
is  an  abundance  of  hair,  the  parts  should  be  well  lubricated  and, 
following  the  massage,  well  washed  with  alcohol. 

Patients  with  skin  diseases  or  fever  should  not  be  massaged. 
Fleshy,  aged,  or  emaciated  persons  should  receive  only  gentle  treat- 
ments. In  these  cases  the  tissues  are  easily  bruised.  In  acute  in- 
flammation, acute  constitutional  diseases  and  cancers,  massage 
should  not  be  given. 

Physiologic  Effect. — In  the  after-treatment  of  operative  cases, 
massage  may  be  used  as  an  aid  to  Nature's  way  of  bringing  to  the 
body  cells  nutrition  and  removing  effete  matter.  Activity  is  the 
fundamental  basis  of  all  life,  and  equally  important  to  the  various 
structural  units  comprising  the  human  body,  the  cell,  tissues,  and 
organs.  In  normal  life  the  body  cells  are  sufficiently  nourished  by 
fact  of  a  constant  supply  of  rich  blood  being  brought  to  the  parts, 


486  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

while  the  products  of  catabolism  are  washed  away,  the  factors 
chiefly  concerned  in  this  procedure  being  the  expulsive  force  of 
the  heart,  the  elasticity  of  the  arterial  walls,  alternate  compression 
and  relaxation  of  the  muscles,  faseire  and  joints,  and  the  thoracic 
suction  force  produced  by  the  negative  atmospheric  pressure  in  the 
thorax.  Following  an  operation  all  of  these  factors  may  be,  while 
in  all  cases  some  of  them  will  be,  affected.  Depending  upon  the 
degree  of  immobility  required  of  the  patient,  a  greater  or  less 
degree  of  assistance  is  taken  from  the  heart  in  its  effort  in  main- 
taining proper  circulation.  The  lymph  flow  too,  as  Starling  has 
pointed  out,  is  entirely  arrested  during  rest.  The  effect  of  this  is 
reflected  unfavorably  on  the  general  bodily  condition.  To  replace 
this  loss  is  one  of  the  chief  functions  of  massage  and  exercise.  If 
there  is  no  acute  inflammatory  process,  cancer  or  fever  present, 
these  measures  are  indicated  in  order  to  improve  the  general  well- 
being  of  the  patient.  Massage  is  particularly  in  place  in  muscular 
and  nervous  exhaustion.  It  feeds  muscle  and  nerve  without  fati- 
guing them ;  active  exercise  on  the  other  hand,  feeds,  but  at  the  ex- 
pense of  nerve  force.  Therefore  at  the  earlier  convalescent  stage 
general  massage  may  be  employed.  As  soon  as  the  condition  of 
the  patient  permits,  mild  passive  and  later  mild  active  exercise  are 
useful,  at  first  in  a  lying  position  and  later  graduating  to  a  sitting, 
and  finally  to  a  standing  position. 

The  effect  of  massage  and  exercise  on  the  digestive  organs  re- 
flects itself  by  way  of  the  improved  circulation,  particularly  by 
removing  visceral  congestion  and  through  reflex  influence  upon  the 
glands  of  the  stomach  and  the  intestines.  Furthermore  the  in- 
testinal mass  may  be  caused  to  move  along  the  colon  by  means 
of  mechanical  manipulation,  and  by  increased  peristalsis  stimula- 
tion. Finally  the  general  increase  in  nutrition  creates  a  demand  for 
an  additional  supply  of  nutriment  which  nature  manifests  by  an  in- 
creased improvement  in  appetite.  In  discussing  elimination,  it 
seems  pertinent  to  mention  the  favorable  effects  of  massage  on  the 
liver  and  kidneys.  The  skin  also  is  made  to  functionate  with  in- 
creased vigor.  This  is  effected  by  a  direct  stimulation  of  the  sweal 
glands  and  reflexly  by  its  influence  upon  the  circulatory  system, 
thus  furnishing  the  skin  with  an  increased  supply  of  blood.  Mas- 
sage manifests  itself  upon  the  nervous  system  in  a  variety  of  ways, 
but  no  attempt  will  be  made  at  this  time  to  enter  into  these  various 
channels.  For  our  purpose,  mention  will  be  made  only  of  its 
stimulative  and  sedative  effect.  For  the  former,  vigorous  friction 
and  percussion  movements  are  used,  for  the  latter,  slow  and  gentle 


EXERCISE   AND    MASSAGE  487 

stroking  or  kneading.  Frequently  bedridden  patients  are  restless 
both  day  and  night.  For  these  cases  a  short  stimulating  massage 
in  the  morning  and  a  sedative  treatment  in  the  evening  would  be 
an  excellent  procedure.  A  properly  performed  sedative  treatment 
is  usually  followed  by  a  peaceful  repose  and  a  satisfied  feeling 
of  well-being.  Frequently  patients  fall  asleep  during  its  administra- 
tion. 

Massage  improves  the  nutrition  of  muscles.  Physiology  teaches 
us  that  a  muscle  which  is  inactive  is  also  poorly  nourished,  and 
we  know  that  an  inactive,  poorly  nourished  muscle  soon  enters 
upon  a  condition  of  atrophy.  Furthermore  we  have  learned  that 
it  is  best  for  a  healthy  muscle  to  functionate  regularly  to  its  com- 
plete extent.  If  this  process  is  interfered  with  for  too  long  a 
time,  the  muscle  will  shorten  by  adapting  itself  to  its  new  mode  of 
requirement.  Massage  and  exercise  would  do  much  to  prevent  these 
untoward  effects. 

The  effect  of  massage  upon  the  red  and  white  blood  cells  and 
hemoglobin  is  interesting.  J.  K.  Mitchell  of  Philadelphia  in  his 
observations  of  thirty-five  persons  suffering  from  various  types  of 
anemia,  some  slight,  others  severe;  some  from  toxic  causes,  others 
malnutrition  and  some  from  hemorrhage,  noted  that  massage  pro- 
duces a  general  increase  in  the  number  of  red  blood  cells  and  in 
about  half  the  cases  an  addition  in  the  hemoglobin.  This  result  has 
since  been  frequently  verified.  The  increase  manifests  itself  one- 
half  to  one  hour  following  the  treatment  and  continues  for  several 
hours.  While  both  white  and  red  cells  are  found  in  large  numbers, 
the  whites  show  a  relatively  greater  increase.  Massage  does  not 
manufacture  blood  cells  or  hemoglobin,  but  merely  puts  into  circu- 
lation those  that  have  remained  dormant  in  the  system,  particularly 
in  the  liver  and  spleen. 

Technic. — The  proper  technic  of  massage  depends  primarily  upon 
a  knowledge  of  normal  and  pathologic  anatomy  and  the  correct  per- 
formance of  the  various  movements.  These  are  not  difficult  to 
learn,  but  the  finer  movements,  the  delicacy  of  touch,  and  a  high 
degree  of  skill  can  only  be  acquired  through  actual  experience. 

The  simplest  classification  divides  massage  into  four  groups.  We 
shall  use  the  French  terms  because  they  are  so  universally  employed. 

Effleurage. — Bffleurage  consists  of  a  stroking  motion  with  the  pal- 
mar surface  of  the  fingers  or  of  the  whole  hand.  It  has  for  its  main 
object  the  emptying  of  the  venous  and  lymph  glands,  the  resultant 
suction  force  bringing  more  blood  to  the  tissue.  The  movements 
should,  therefore,  follow  the  outlines  of  the  muscles,  beginning  with 


4- 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


Fig.  165. — E^eurage,  foot  held  firm  with  operator's  left  hand,  firm  stroking  towards  toes  right 

hand 


\ 


Fig.  166. — Diamond  effeurage.  Beginning  at  the  coccyx  apply  pressure  on  both  sides  of 
the  spine  upward  to  the  7th  cervical,  effleurage  by  placing  palm  of  hands  on  back,  apply  firm 
stroking  motion  downward  to  pelvis. 


a  gentle  pressure  a1  the  insertion,  increasing  to  its  maximum  in- 
tensity at  the  belly  of  the  muscle  and  concluding  with  decreased 
pressure  a1  the  origin.  The  effort,  where  possible,  should  be  made 
to  surround  the  muscle  with  the  whole  hand,  applying  a  grasping 


EXERCISE   AND    MASSAGE 


489 


Fig.    167. — Draining  the   jugular  veins 


Fig.    168. — Alternate  wringing   of   the   flexor   muscles.     Hold   leg   in   position  with   right   hand, 
wring  the   muscle  with   the   left. 

motion.  On  the  trunk  or  upper  thigh  where  this  can  not  be  done, 
direct  pressure  against  the  more  solid  and  deeper  tissues  should  be 
made.  Effleurage  should  form  the  beginning  and  ending  of  every 
treatment  and  may  be  injected  at  any  other  time.    It  is  particularly 


490 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


useful  for  the  removal  of  exudations  following  fractures  and  joint 
disturbances.     If  instead  of  the  above-described  stimulating  move- 


1     ' 


Fig.   169. — Kneading  of  the  patella      Log  in   a  flexed  position.      Both   hands  cover  the  patella. 
Knead   outward   and    upward. 


Fig.    1~0. — Alternate   kneading   of   the   flexors   of   the   thigh,   beginning   at   the   upper   part   and 

working  toward  the  knee. 

ment.  a  sedative  effed  is  desired,  the  stroking  should  be  very  gentle 
with  the  tips  .»('  the  fingers  barely  touching  the  skin  in  a  centrifugal 
direction.     It   is  1  liis  form   of   massage   which   is  not   uncommonly 


EXERCISE   AXD    MASSAGE 


491 


followed  by  a  restful  sleep.  It  is  indicated  in  cases  of  restlessness, 
certain  forms  of  headaches,  neuralgia  and  neurasthenic  pains  fFies' 
165  and  166.) 

Petrissage.— By  this  term  is  meant  deep  or  superficial  kneading 


Fig.   171.— Pulling  and  pushing  of  the  flexors  and  extensors  of  the 


Fig.   172.— Thumbs  kneading  the  anterior  muscles   of  the  leg. 


of  the  muscles  together  with  grasping,  pinching,  rolling,  pressing 
and  stretching  of  the  underlying  tissues.  One  hand  may  grasp  as 
much    tissue    as    possible,    lifting    or    squeezing   it,   repeating    this 


492 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


manipulation  until  the  entire  muscle  group  is  covered.  Or  one  hand 
may  alternate  with  the  other;  or  again,  one  hand  may  work  on  the 
anterior  while  the  other  on  the  posterior  part  of  the  limb.     Again 


Fig     173. — Anterior   frictional   kneading   of   the    thigh    alternate   up   and    down. 


l"ig.    174. — Fist   kneading  of  the  small   intestines.      Place    fists   one   inch   above  and   to   the   side 
of    the    umbilicus,    alternate    knead    down    to    one    inch   below    the   umbilicus. 

the  tissues  may  be  caught  between  the  thenar  eminence  of  both 
thumbs  and  rolled  againsl  themselves  or  against  the  underlying 
tissues.  Another  type  of  petrissage  consists  in  supporting  a  Limb 
with  one  hand  and  grasping  the  fleshy  portion  with  the  other,  push- 


EXERCISE   AND    MASSAGE 


493 


Fig.  175. — Circular  muscular  kneading  of  the  thigh,  beginning  at  the  upper  part  and  work- 
ing toward  the  knee,  place  the  hands  firmly  on  either  side  of  the  thigh  and  roll  the  muscle 
around  the  bone. 


Fig.  176. — Breaking  up  adhesions.  Place  one  hand  on  the  side  of  the  scar  and  hold  in 
position.  The  other  hand  is  placed  on  the  opposite  side  and  rolls  or  pulls  the  tissues  against 
the  counterpressure. 


494 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


ing  and  pulling  it  in  the  direction  of  the  long  axis.  This  procedure 
is  especially  useful  in  muscular  spasm  and  the  stretching  of  con- 
tracted tissues.  Petrissage  is  a  decidedly  stimulating  measure 
acting  on  all  the  vital  functions.  It  brings  about  circulatory 
changes,  improves  muscle  tone,  serving  very  much  as  an  active 
exercise.     (Figs.   167-175.) 

Friction. — This  term  does  not  signify  merely  rubbing  over  the 
skin  which  is  a  motion  akin  to  gentle  stroking,  but  instead  consists 
of  a  series  of  rotary  motions  executed  by  the  tips  of  one  or  more 
fingers,  the  thumb  resting  quite  firmly  on  the  skin  and  moving  it 
over  the  underlying  tissues.  It  is  especially  useful  in  loosening 
adherent  tissue  and  therefore  is  employed  a  great  deal  in  the  treat- 


Fig    1"~. — Cupping. 

ment  of  abnormal  joint  and  scar  conditions.  It  also  tends  to  relieve 
local  congestion  by  lending  aid  in  the  forward  movement  of  the 
venous  and  lymph  currents.     I  Pig.  176.) 

Tapotement  of  Percussion,  consists  of  a  series  of  blows  delivered 
with  a  flexible  wrist  to  avoid  bruising  of  the  tissues.  Various 
methods  of  percussion  are  employed  : 

(a)  Clapping  is  performed  with  the  palmar  surface  of  the  hand 
so  shaped  as  to  form  a  cup.     The  hands  are  alternately  brought 


EXERCISE    AND    MASSAGE 


495 


down  producing  a  resounding  effect.     This  serves  as  a  stimulant  to 
the  skin  (Fig.  177). 

(b)  Hacking  is  applied  with  the  ulnar  surface  of  the  hand,  the 
fingers  being  held  rigid  and  close  together  or  relaxed  and  separated. 
This  is  applied  particular^  to  large  masses  of  muscles  and  along 
nerve  trunks  (Fig.  178). 

(c)  Slapping  is  performed  with  the  flat  of  the  hand.  This  excites 
the  peripheral  nerve  endings. 

(d)  Tapping  is  a  measure  executed  with  the  tips  of  the  fingers. 
It  is  used  chiefly  along  nerve  trunks,  whenever  the  bone  lies  close 
to  the  skin  or  in  scalp  treatment. 


Fig.    178.— Hacking 


Vibration 

Vibration  may  be  transmitted  to  the  body  in  a  variety  of  ways  all 
tending  to  produce  either  locally  or  generally  a  more  or  less  rapid, 
to  and  fro  motion  of  the  tissues.  Manually  it  may  be  performed  by 
pressing  one  or  more  finger  tips  firmly  against  the  part  to  be 
treated  and  executing  rhythmic  movements  at  the  rate  of  from  eight 
to  ten  times  per  second.    The  act  may  be  localized  or  it  may  follow 


496  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

the  course  of  a  nerve  trunk.  This  method,  however,  is  very  tiring 
on  the  operator  and  can  be  sustained  for  a  short  period  only,  for 
which  reason  various  types  of  apparatus  have  been  invented,  some 
of  "which  are  very  good. 

Portable  Apparatus. — The  more  general  way  of  performing  vibra- 
tion is  by  means  of  an  electrically  propelled  apparatus  which  im- 
parts to  the  tissues  a  rapid  rotary  or  lateral  motion  ranging  in 
velocity  from  1000  to  6000  per  minute  and  even  more.  A  variety 
of  applicators  are  used  in  connection  with  the  machines. 

Stationary  Apparatus. — The  most  popular  of  this  form  of  ap- 
paratus is  the  vibratory  chair,  so  constructed  that  the  whole  body, 
or  parts  thereof,  if  desired,  may  be  treated  at  the  same  time.  The 
oscillatory  movements  may  be  regulated  as  to  speed  and  length 
of  movement.    There  are  various  modifications  of  this  type. 

Shaking  and  Kneading-  Appliances. — The  use  of  this  type,  as  well 
as  the  chair  just  described,  is  almost  entirely  limited  to  institutional 
use.  Their  action  approaches  more  nearly  a  mechanical  massage 
than  vibration.  The  trunk  shaker  is  an  apparatus  which  has  at- 
tached to  it  an  eccentrically  revolving  wheel.  The  patient  stand- 
ing in  an  upright  position  allows  his  body  to  rest  against  a  belt 
attached  to  the  wheel.  The  resultant  action  is  a  violent  shaking 
of  the  body. 

The  mechanical  horse  acts  by  bouncing  the  riding  individual  at 
a  regulated  speed  and  distance. 

The  kneading  table  acts  by  means  of  four  to  six  uprights  which 
project  through  an  opening  in  a  table  and  operate  on  the  ab- 
domen of  the  patient  lying  prone.  Here  too  the  speed  and  distance 
of  movements  are  adjustable. 

Physiologic  Effect. — The  particular  effect  of  vibration  is  general 
stimulation,  causing  rapid  but  small  muscular  contractions.  At 
first  the  superficial  blood  vessels  are  contracted  then  dilated.  If 
applied  along  a  nerve  trunk  a  diminished  sensibility  may  be  brought 
about,  for  which  reason  this  method  is  sometimes  used  in  connec- 
tion with  the  treatment  of  neuritis  and  neuralgia. 

Applied  to  the  heart  the  pulse  may  be  caused  to  beat  slower  but 
stronger.  It  has  been  used  successfully  in  relieving  muscular  spasm, 
a  fact  first  noted  by  Charcot  who  used  vibration  in  the  treatment 
of  paralysis  agitans. 

The  shaking  and  kneading  movements  are  Used  principally  in 
cases  of  obesity  and  constipation. 


EXERCISE   AXD    MASSAGE  497 

Exercise 

Today  exercise  is  regarded  by  the  laity  as  well  as  by  the  pro- 
fession as  a  synonym  of  health.  Xo  one  agency  in  the  whole 
category  of  the  laws  of  personal  hygiene  has  received  such  impetus 
as  has  that  of  exercise.  Young,,  middle  age.  and  old  of  both  sexes 
indulge  in  it  as  never  before.  Public  schools,  colleges  and  even 
municipalities  recognize  its  value  and  spend  much  money  in  its 
promotion.  It  seems  therefore  reasonable  for  the  medical  profes- 
sion to  consider  this  agency  from  the  standpoint  of  therapeutics 
and  add  it  to  the  present  established  methods  of  postoperative 
treatment.  To  gain  a  clearer  understanding  of  its  therapeutic  value 
we  classify  exercise  into  various  forms. 

We  speak  of  an  active  exercise  as  one  which  follows  an  effort 
of  the  will.  It  is  voluntary  on  the  part  of  the  individual  and  may 
be  executed  with  or  without  assistance. 

A  passive  exercise  is  performed  by  an  operator,  or  apparatus, 
on  a  patient  without  the  latter 's  assistance  or  resistance  and  has 
no  connection  with  the  will  of  the  patient. 

Resistive  exercises  are  performed  by  the  patient,  the  operator 
resisting  the  active  muscle  becoming  shorter.  This  is  spoken  of  as 
positive  concentric  in  action.  Or  the  operator  performs  the  move- 
ment while  the  patient  resists,  in  which  case  the  active  muscle  be- 
comes longer,  negative,  or  excentric  in  action.  This  latter  form  for 
instance,  is  used  in  cases  where  the  muscles  are  still  too  weak  to  use 
concentrically. 

Movements  of  skill  are  primarily  active  exercises  involving  the 
coordination  of  the  nervous  and  muscular  systems.  It  means  edu- 
cating the  muscle  to  perform  an  act  with  the  least  expenditure  of 
nerve  energy  and  requires  strict  and  concentrated  attention.  As 
examples  may  be  cited  the  swinging  of  Indian  clubs,  fancy  skating, 
walking  a  railroad  track,  or  it  may  be  of  a  more  violent  form  like 
foil  fencing,  tumbling  or  tennis  playing.  "When  such  an  exercise 
is  first  begun,  fatigue  quickly  sets  in,  because  an  unnecessary  num- 
ber of  motor  nerve  impulses  are  being  sent  from  the  brain,  not  only 
to  the  muscles  involved  in  the  correct  performance  of  the  act,  but 
to  other  groups  as  well,  including  often  its  antagonistic  fellows. 
Furthermore  a  failure  to  send  inhibitory  impulses  to  the  antagonistic 
group  increases  the  disturbance  of  the  normal  neuromuscular 
mechanism  so  that  there  occurs  a  more  or  less  irregular  and  hap- 
hazard contraction  and  relaxation  of  muscles  producing  an  awk- 
ward exercise,  not  at  all  that  which  the  individual  had  willed  to  do. 


498  AFTER-TREATMENT   OP    SURGICAL   PATIENTS 

The  muscles  soon  tire  and  refuse  to  respond  to  the  will  because  of 
the  exhausted  condition  of  the  motor  cells.  Nerve  cells  fatigue 
quicker  than  the  muscle  cells  which  they  innervate.  Obviously,  ex- 
ercises involving  such  close  attention  are  not  indicated  in  persons 
already  suffering  from  nerve  exhaustion.  For  these  patients  pas- 
sive motion,  joint  movements,  and  massage  serve  the  purpose  very 
much  better,  for  here  muscles  are  fed  with  new  blood  without  brain 
expenditure.  These  latter  measures,  however,  should  be  replaced 
as  soon  as  the  patient's  condition  warrants  it,  by  mild  active  ex- 
ercise, because  the  general  physical  effect  of  the  latter  is  of  greater 
value  as  a  general  body  building  measure  than  massage  or  passive 
exercise.  Neither  should  exercise  folloAving  a  command,  like  march- 
ing tactics,  or  a  new  wand  or  dumb-bell  drill  be  given  in  these  cases 
because  of  the  concentrated  attention  necessary.  This  is  a  valid 
reason  why  mentally  tired  school  children  and  business  men  prefer 
playing  games  to  formal  gymnastics.  Because  of  the  great  mental 
activity  involved  in  this  class  of  exercise  they  are  termed  edu- 
cational. Oftentimes  repetition  of  these  intricate  movements 
finally  results  in  their  performance  with  an  increasingly  less  ex- 
penditure of  nerve  force  because  of  properly  directed  stimulating 
and  inhibitory  impulses,  and  therefore  are  less  fatiguing.  They 
then  become  less  educational  in  character  and  no  longer  stimulate 
the  element  of  discipline.  Applied  therapeutically,  an  accomplished 
tennis  player,  following  an  illness,  can  more  quickly  resume  his 
game  with  profit  than  the  individual  who  is  just  learning  to  play. 
Contrariwise  exercises  of  effort  involving  decided  mental  action  may 
be  properly  given  to  persons  of  sedentary  habits,  not  of  a  too  active 
brain,  to  whom  active  exercise  is  a  drag  even  when  in  the  best  of 
health.  Exercises  of  effort  vary  from  a  single  act  like  lifting  a  heavy 
weight  to  a  simple  exercise  frequently  and  quickly  repeated,  like 
jumping  a  rope,  racing,  and  games  of  like  nature.  In  a  violent  form 
of  effort  practically  every  muscle  group  in  the  body  is  involved 
even  to  the  facial  group.  This  has  been  so  interestingly  described 
by  McKenzie  of  the  University  of  Pennsylvania.  Witness  the  drawn 
face  of  an  athlete  at  the  finish  of  a  race.  This  form  of  exercise 
demands  a  great  deal  of  nerve  expenditure  and  should  not  be  given 
in  cases  where  it  seems  desirable  to  conserve  nerve  force.  In  this 
case  we  place  most  of  our  modern  athletic  performances  like  sprints, 
hurdles,  the  long  runs,  pole  vaults  and  jumps;  basket,  hand,  and 
foot  ball.  These  exercises,  however,  are  classified  as  acts  of  effort 
only  so  long  as  attempts  at  maximum  intensity  are  made.  If,  for 
instance,  a  given  run  be  covered  at  a  minimum  rate  of  speed,  it 


EXERCISE   AND    MASSAGE  499 

becomes  an  exercise  of  mild  or  severe  endurance,  depending  upon 
the  distance  run.  The  physiologic  effect  is  decidedly  different  from 
that  following  an  exercise  of  effort.  Thus  while  a  distance  of 
several  hundred  yards  run  slowly  would  become  an  act  of  endurance 
and  an  excellent  prescription  for  a  boy  with  a  so-called  weak  heart, 
it  is  decidedly  contraindicatecl  if  the  distance  were  run  at  maxi- 
mum speed  and  thereby  became  an  exercise  of  supreme  effort.  Be- 
cause of  a  failure  to  appreciate  these  conditions  many  a  young  man 
has  been  denied  mild  athletic  exercise  by  his  doctor,  which  might 
have  been  of  help  to  him.  It  is  exercise  of  mild  endurance  which 
may  be  of  particular  helpfulness  to  physicians.  They  involve  acts 
demanding  a  minimum  expenditure  of  nerve  force.  Included  in 
this  class  we  place  hiking,  rowing,  a  mild  game  of  tennis  of  not 
too  keen  competition,  golf  and  noncompetitive  swimming.  Ex- 
ercises of  this  type  are  very  beneficial  for  strengthening  the  heart 
and  general  body  building. 

Mild  exercises  of  strength  constitute  another  form  of  activity  well 
suited  for  the  convalescent,  for  they  require  little  skill  and  may 
be  indulged  in  while  the  patient  is  yet  in  bed.  Some  effort  at 
attention  is  necessary,  but  the  essential  requirement  is  to  attempt 
as  complete  a  contraction  as  possible.  It  is  this  type  of  exercise 
which  increases  the  bulk  of  the  muscle  and  is  therefore  used  for 
general  developmental  purposes.  Appropriate  movements  at  the 
earlier  stage  might  consist  of  arm  and  leg  movements  in  the  various 
directions,  executed  as  either  voluntary,  active  or  resistive. 

Physiologic  Effect  of  Exercise. — No  part  of  the  body  is  more  pro- 
foundly affected  by  exercise  than  the  great  mass  of  voluntary  mus- 
cle. The  effect  is  directed  in  a  line  of  increased  bulk  and  in  an 
increase  of  strength  and  endurance,  the  former,  however,  not  de- 
veloping in  direct  ratio  with  the  latter.  One  may,  for  instance, 
exercise  the  biceps  until  its  maximum  girth  is  attained,  after  which 
no  amount  of  additional  exercise  will  increase  the  circumference 
of  the  upper  arm.  The  endurance  and  strength  of  it  may,  however, 
keep  on  growing  towards  a  greater  maximum.  This  is  explained 
by  the  fact  that  active  exercise  will  not  oinV  strengthen  the  mus- 
cles, per  se,  but  also  the  nerve  force  causing  its  contraction.  In 
others  words,  active  exercise  prompted  by  the  individual  himself 
is  a  force,  and  the  only  force,  which  causes  an  increased  power 
and  efficiency  of  the  neuro-muscular  apparatus,  involving  as  it  does 
for  its  execution  the  functioning  of  nerve  cells  situated  in  the 
seat  of  higher  consciousness,  the  motor  areas  and  elsewhere,  the 
central  nervous  system,  as  also  the  muscle  tissue  itself.    This  is  not 


500  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

true  with  respect  to  passive  movement  or  massage.  It  is  for  this 
reason  that  we  aim  to  treat  paralytics  by  means  of  active  exercise 
as  soon  as  this  may  be  permitted. 

Through  the  muscular  system,  exercise  powerfully  affects  other 
vital  activities.  The  circulation  is  hastened  and  the  lymph  is  pro- 
pelled along  its  channels.  Breathing  becomes  deeper  and  fuller, 
aiding  thereby  the  return  circulation,  increasing  the  carbon  diox- 
ide output  and  the  oxygen  intake.  The  effect  of  exercise  on  the 
heart  has  long  been  misunderstood.  McKenzie  of  Philadelphia  has 
gathered  data  which  seems  to  disprove  the  generally  accepted 
thought  that  athletics  are  harmful  to  the  college  student.  To  be 
sure  if  untrained  individuals  with  weak  hearts  are  subjected  to 
violent  exercise  the  inevitable  harm  will  follow  On  the  other 
hand  observation  and  experience  and  research  seem  to  give  an 
abundance  of  conclusive  evidence  to  the  effect  that  athletics  prac- 
ticed under  safeguarded  conditions  may  be  an  excellent  heart 
strengthening  agent.  The  pulse  rate  and  blood  pressure  rise  quite 
decidedly  and  the  heart  increases  in  size  but  these  return  to  normal 
in  a  surprisingly  short  space  of  time.  Tins  is  even  true  with  re- 
spect to  the  more  violent  forms  of  exercise  like  rowing,  wrestling, 
marathon  running,  heavy  lifting,  and  mountain  climbing.  The 
criterion  as  to  whether  the  heart  is  capable  of  performing  a  given 
amount  of  work  is  found  in  the  fact  that  following  muscular  ex- 
ercise there  will  be  a  definite  rise  in  the  pulse  rate  and  blood  pres- 
sure and  that  these  will  return  to  the  normal  at  the  expiration  of 
a  given  period,  depending  upon  the  amount  of  work  done.  In  one 
of  the  British  hospitals  a  covenienl  test  is  employed  to  determine 
the  heart  efficiency.  A  soldier  is  required  to  raise  his  body  weight 
twenty  feet  in  not  longer  than  30  seconds,  e.  g.,  running  up  a  flight 
of  stairs.  He  is  considered  as  having  a  "good  reaction"  if  his  pulse 
and  respiratory  rate  and  Mood  pressure  return  to  normal  at  the  end 
of  three  minutes. 

General  Outline  of  Exercise  Treatment  for  the  More  Common  In- 
dications.— Select  at  first  a  mild  grade  of  movements  and  graduate 
to  the  more  severe  type.  Exercise  preferably  twice  a  day  and  con- 
tinue to  a  mild  degree  of  fatigue,  then  stop.  If  physical  conditions 
permit,  it  is  well  to  follow  the  exercise  with  a  mild  tonic  hydriatic 
procedure  and  a  general  massage  once  a  day. 

I.  For  relaxal  abdominal  muscles  common  with  enteroptosis,  con- 
stipation (except  spaslic  type),  puerperium,  faulty  posture,  con- 
valescence, etc.: 


EXERCISE    AND    MASSAGE  501 

Lying  position  arms  at  side. 

1.  Head  raising  with  rotation. 

2.  Trunk  raising,  chest  leading  shoulders  back,  with  exhalation. 
Raise  from  1  to  6  inches. 

3.  Leg  raising  first  one  then  the  other.  6  inches. 

4.  Same  with  knees  flexed,  later  with  resistance. 

5.  Knees  flexed,  abduction  and  adduction,  later  with  resistance. 

6.  Bring  flexed  knees  towards  chest  slowly,  exhaling  to  prevent 
undue  intraabdominal  pressure. 

7.  Bring  one  flexed  knee  toward  shoulder  of  opposite  side. 

8.  Retract  abdominal  muscles  as  much  as  possible  with  deep  chest 
raising  and  inhalation. 

9.  Keeping  shoulders  down  roll  legs  and  hips  to  opposite  side. 
Later  with  knees  flexed,  then  legs  extended  upward. 

10.  With  hands  on  hips  raise  trunk  to  sitting  position.  Later 
hands  on  neck  or  arms  extended  upward. 

11.  See  exercises  on  Hernia. 

12.  If  used  for  enteroptosis.  it  is  well  to  raise  foot  end  of  table 
12  to  15  inches. 

Sitting  position  on  straight  chair  with  feet  resting  on  floor. 
13'.  Alternate  knee  raising;  later  both. 

14.  Knee  raising  with  abduction  and  adduction ;  later  with  both, 
and  then  with  resistance. 

15.  Knee  raising  with  alternate  extension. 

16.  Extended  leg  raising  with  abduction  and  adduction. 
Sitting  on  stool. 

17.  With  legs  fixed,  or  supported  by  nurse,  incline  trunk  back- 
ward.    Hands  on  hips,   on  neck   or   extended  upward. 

18.  Same  position  as  17  with  trunk  circumduction. 

19.  Same  as  above  with  trunk  twisting. 
Hanging  position. 

20.  From  mild  type  of  knee  flexion  to  knee  extension  with  ab- 
duction and  adduction. 

II.  Exercise  to  improve  posture.  It  is  very  important  that  all 
standing  exercises  should  have  as  a  starting  position  a  correct 
posture.  Caution  not  to  exaggerate.  A  good  standing  posture  is 
one  in  which  the  body  weight  is  so  balanced  that  no  undue  strain 
is  placed  on  any  muscle  group  or  pelvic  ligaments ;  the  important 
pivotal  points  of  the  body,  the  ankle,  knee,  hip,  are  practically  in  a 
straight  line,  with  the  body  weight  transferred  largely  forward  on 
the  forepart  of  the  foot ;  the  chest  is  held  high,  the  abdominal  con- 


502  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

tour  almost  flat ;  the  physiologic  spinal  curves  slightly  dorso-con- 
vexed  and  lumbar-concaved;  the  pelvis  inclined  forward  about  60° 
from  the  horizontal.  In  such  an  attitude  the  gluteal  prominence 
and  the  dorsoconvexity  are  in  the  same  perpendicular  which  line 
falls  approximately  two  inches  back  of  the  heel.  To  maintain  this 
attitude  it  is  necessary  to  have  a  normal  skeleton  and  a  healthy  and 
well-trained  neuromuscular  system.  Conditions  which  influence  this 
posture  abnormally  are:  fa)  a  change  in  the  bony  architecture  (b) 
weak,  atrophied  or  stretched  muscles  and  ligaments  (c)  disturbance 
of  part  of  the  nervous  system.  It  is  further  influenced  by  incorrect 
shoes  and  bad-fitting  corsets. 
Treatment  consists  in: 

(a)  Removal  of  the  cause  i.  e..  bony  defects,  poor  shoes  or  corsets, 
conditions  maintaining  poor  posture. 

(b)  Strengthening  of  musculature. 

(c)  Training  a  proper  balance  sense.  For  this  purpose  we  em- 
ploy general  massage,  exercise  and  hydrotherapy.  The  patient  is 
given  a  treatment  in  exercise  and  posture  which  is  followed  by  any 
of  the  tonic  hydriatic  procedures.  Preferably  we  use  the  Scotch 
jet  douche  because  of  its  powerful  tonic  effects  on  the  whole  body. 
Massage  may  follow  in  selected  cases. 

Exercise.  Active  exercises  only  should  be  employed.  Generally 
speaking  the  patient  should  be  encouraged  to  engage  in  all  of  the 
common  out-of-door  games.  Indoor  exercises  should  aim  especially 
towards  developing  the  scapula'  retractors,  the  stretching  of  soft 
contractures  of  the  anterior  shoulder  girdle,  the  strengthening  of 
the  abdominal  group,  to  hold  the  chest  high  and  learn  correct 
breathing.  If  apparatus  is  available,  a  good  part  of  the  work  should 
consist  of  stretching  and  hanging  exercises,  also  balancing  exercises 
of  various  types.  The  day's  order  should,  of  course,  include  ab- 
dominal exercises,  examples  of  which  are  described  elsewhere.  For 
chest,  back  and  general  development,  the  following  may  serve  as  a 
guide. 

(a)  Arms,  chest  and  had:  exercises. 

21.  Arms  extended  sideward.  Touch  shoulders  with  finger  tips. 
extend  the  arms  forcibly  side  and  upwards,  always  behind  the  body 
line. 

22.  Elbows  sideward,  shoulder  high,  thumbs  touching  chest, 
palms  down.  Fling  anus  forcibly  backward  with  palms  facing  up- 
wards. 


EXERCISE   AND    MASSAGE  503 

23.  Arms  extended  sideward.  Lower,  cross  in  front,  continue  to 
full  extension  over  head.  Reverse  direction.  Keep  hips  back  and 
weight  well  on  ball  of  feet. 

24.  Arms  extended  sideward.  Make  circle  two  feet  diameter, 
reverse.  Emphasize  backward  motion  and  keep  arms  behind  body 
line. 

25.  C4rasp  hands  behind  body.  Raise  the  stretched  arms  backward 
and  upward  with  head  bending  backward. 

(&)  Leg  exercises,  standing  position.  Leg  and  arm  exercises  should 
alternate  with  trunk  movements. 

26.  Hands  on  hips.  Alternately  raise  extended  leg  forward,  side- 
ward and  backward. 

27.  Bring  left  heel  towards  right  hip.    Reverse. 

28.  See  flat  foot  exercises. 

29.  Hands  on  hips.  Deep  knee  bending  with  knees  directed  out- 
ward and  heels  raised ;  trunk  erect. 

30.  Alternate  toe  and  heel  raising. 

31.  Standing  on  one  foot  perform  various  movements  with  the 
other. 

(c)   Trunk  exercises,  standing  position. 

32.  Trunk  bending  with  back  held  straight,  hands  on  hips,  then 
on  neck,  elbows  back,  then  extended  over  head. 

33.  Same  as  32  trunk  bending  sideward. 

34.  Hands  on  hips,  trunk  circumduction. 

35.  Hands  extended  sideward,  feet  together,  twist  trunk  right 
and  left  as  far  as  possible  without  moving  feet. 

36.  Hands  on  hips,  twist  hips  to  the  right,  the  head  to  the  left 
as  far  as  possible.    Alternate. 

37.  Trunk  bending  forward  touching  floor  with  finger  tips. 
(cZ)  Abdominal  exercises,  see  Exercise  1. 

(e)  Breathing  exercises.  Breathing  exercises  produce  certain 
definite  physiologic  effects  upon  the  body.  They  may  be  prac- 
ticed in  almost  any  position  and  during  any  part  of  the  wakeful 
period  and  without  preliminary  preparations.  They  are  therefore 
of  great  value  to  us  in  cases  of  bedridden  patients. 

Primarily  we  use  deep  breathing  as  a  means  for  strengthening 
the  respiratory  muscles,  thus  helping  to  keep  the  chest  up  and 
improving  faulty  posture.  It  promotes  a  more  complete  aeration 
of  the  lungs  by  putting  into  action  certain  portions  of  lung  tissue 
which  would  otherwise  remain  more  or  less  quiescent.  It  very 
definitely  aids  the  return  venous  circulation  by  its  suction  action 


504  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

on  the  large  veins.  Deep  breathing'  exercises  promote  a  greater 
mobility  of  the  chest  vail.  We  recognize  two  distinct  types  of 
breathing,  the  thoracic  or  costal  and  the  abdominal  or  diaphrag- 
matic; the  former  is  practiced  almost  to  the  exclusion  of  the  latter 
wherever  the  waist  line  is  constricted,  either  by  corset  or  belt.  It 
seems  best,  however,  that  both  be  developed  and  used. 

There  are  three  kinds  of  deep  breathing;  voluntary,  against  re- 
sistance and  forced  breathing.  The  first  form  is  self-explanatory. 
The  second  type  may  be  produced  by  blowing  through  a  thin 
tube,  into  a  respirometer,  musical  instruments,  etc.  This  form  is 
particularly  useful  in  the  treatment  of  asthma,  emphysema,  and 
postoperative  contractures  or  scars.  Forced  breathing  is  the  result 
of  running,  jumping  and  other  forms  of  violent  exercise. 

Although  deep  breathing  may  be  practiced  in  any  position,  the 
lying  supine  and  standing  positions  are  best  suited  because  of  a 
greater  freedom  of  restriction  than  is  the  case  in  sitting  position. 

Examples  of  breathing  exercises: 

38.  May  be  practiced  in  combination  with  arm,  leg  or  trunk  move- 
ments, but  more  particularly  with  first  named  type. 

39.  In  bed  with  arm  raising,  later  against  resistance. 

40.  "While  walking.  Ten  or  twenty  deep  breaths  several  times 
each  clay. 

41.  Standing  with  hands  against  abdomen  and  inhale  deeply;  ex- 
hale forcibly  by  drawing  in  abdominal  wall. 

42.  Same  position  as  40  but  using  thorax  only. 

4:!.  Arms  forward  upward  raising  with  heels  raising  and  deep 
inhalation.  Stretch  as  high  as  possible.  Lower  arms  and  exhale 
slowly. 

44.  Same  as  42  except  exhale  with  rapid  chest  slapping  from 
above  downward. 

Special  Exercises  for  Strengthening  the  Heart. — The  value  of  se- 
lect ive  bodily  exercise  and  certain  kinds  of  baths  in  the  treatment 
of  dilatation  and  other  functional  disturbances  of  the  heart  has 
long  ago  been  established.  Very  serious  organic  changes  in  the 
heart  and  vascular  system  are  not  suitable  for  physical  treatment. 

Muscular  exercise  was  first  prescribed  for  "symptoms  of  breath- 
lessness  and  debility  of  the  heart"  by  Sir  \Vm.  Stokes  as  early  as 
1854.  Since  then  it  has  had  its  advocates  among  the  medical  pro- 
fession to  this  day.  As  a  result,  a  number  of  systems  were  evolved 
all  based  on  the  same  type  of  exercise,  viz.,  mild  effort  and  en- 
durance, but  the  methods  differed  somewhat.    Today  there  are  two 


EXERCISE    AND    MASSAGE  505 

systems  practiced,  the  Oertel  system  of  graduated.  Mil  climbing  and 
the  brothers  Schott  system  of  graduated  resistive  exercises.  Only 
the  latter  is  practiced  in  America,  and  then  almost  always  in  con- 
nection with  effervescent  baths.  The  plan  has  had  the  endorsement 
of  some  of  the  most  prominent  physicians  of  England  and  America. 
In  this  list  we  find  the  names  of  Sir  Brunton,  Sir  Broadbent,  Sir 
Stewart,  Satterthwaite  and  others  of  England,  and  Anders,  Bab- 
cock,  Billings,  Osier,  Osborne,  Tyson  and  Ellsworth  Smith  of 
America.  In  the  first  stages  of  functional  disturbance  Dock  of  St. 
Louis  prescribes  mild  tonic  hydriatic  procedures  and  general  mas- 
sage.   He  reports  marked  success  in  cases  of  auricular  fibrillation. 

Dr.  Theodore  Schott  defines  the  essential  characteristics  of  the 
plan  as  given  below.  For  details  the  reader  is  referred  to  his 
book. 

Summary  of  important  regulations  governing  the  passive  re- 
sistance exercises. 

"1.  Passive  resistance-movements  include  abducation,  adduction, 
flexion,  extension  and  rotation  in  a  vertical,  horizontal  or  lateral 
direction. 

"2.  These  movements  should  so  alternate  that  new  groups  of 
muscles  are  continuously  made  to  act  in  sequence  thus  avoiding 
fatigue. 

"3.  The  resistance  should  be  made  by  the  operator  as  slowly 
and  gently  as  possible,  but  with  as  much  firmness  and  muscular 
power  as  the  patient's  physical  condition  will  warrant. 

"4.  The  operator  should  never  grasp  the  patient's  limb  tightly, 
but  should  oppose  its  movements  by  firm  eounterpressure  against 
the  advancing  side,  thus  retarding  the  movement,  but  always  per- 
mitting the  patient  to  retain  the  'balance  of  power.' 

"5.  The  operator  should  change  his  resistance  whenever  the  di- 
rection of  the  physical  force  is  changed. 

"6.  To  gain  a  well-balanced  and  uniform  effect  these  exercises 
should  always  be  bilateral. 

"7.  The  operator  should  closely  watch  the  patient's  breathing 
and  circulation  and  at  the  slightest  sign  of  embarrassment  should 
stop  the  exercises.  The  patient  should  never  be  allowed  to  hold 
his  breath  while  exercising. 

"8.  A  pause  of  one  or  two  minutes  should  be  allowed  between 
each  exercise  in  order  to  avoid  any  fatigue.  The  patient  may  sit 
down  during  the  pause,  especially  during  the  latter  half  of  the 
seance. 


506  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

"9.  The  length  of  time  devoted  to  each  seance  should  be  about 
a  half-hour.  At  the  end  of  that  period  it  will  frequently  be  found 
that  the  number  of  heart  beats  has  been  reduced  from  10  to  15  per 
minute  and  that  the  area  of  cardiac  dullness  has  been  made  to  eon- 
tract  an  inch,  more  or  less. 

"10.  After  the  seance  is  finished  the  patient  should  rest  quietly 
on  a  couch  for  at  least  15  minutes." 

The  following  series  of  exercise  constitute  what  is  known  as  group 
one.  Additions  of  the  same  type  of  exercises  are  made  until  the 
number  reaches  fifteen  in  group  four. 

1.  Raise  the  arms  slowly  outward  from  the  side  until  on  a  level 
with  the  shoulder.     After  a  pause  slowly  lower  to  position. 

2.  Extend  one  leg  as  far  as  possible  sideways  from  the  body,  the 
patient  steadying  himself  by  holding  on  to  a  chair.  Same  with  the 
other  leg. 

3'.  Extend  arms  in  front  of  body  to  a  level  with  shoulders,  and 
then  put  down. 

4.  One  leg  is  raised  with  the  knee  straight  forward  as  far  as 
possible,  then  brought  back.     Repeat  with  the  other  leg. 

5.  With  fists  supinated,  the  arms  are  extended  outward  and  next 
inward  at  the  level  of  the  shoulders. 

G.  Raise  each  knee  as  far  as  possible  to  the  body  and  then  extend 
leg. 

7.  With  lists  pronated  extend  arms  as  in  Exercise  5. 

8.  Each  leg  is  bent  backward  from  the  knees  and  then  straight- 
ened. 

Hernia. — The  best  security  against  hernia  is  a  Avell-developed 
muscular  abdominal  wall.  By  its  contractions  it  aids  powerfully 
in  keeping  the  abdominal  contents  in  their  proper  place.  A  weak- 
ness of  this  defensive  wall  plus  sudden  or  continuous  strain  pro- 
duces an  increased  intraabdominal  pressure  which  may  result  in 
an  adbominal  hernia.  In  cases  of  muscular  atony  following  lessened 
activity,  especially  with  localized  deposits  of  fat;  or  women  with 
general  muscular  weakness  induced  by  prolonged  illness,  pro- 
phylactic measures  of  massage  or  exercise  may  well  be  instituted. 
Or,  if  acquired,  these  same  measures  will,  with  the  wearing  of  a 
truss,  in  selected  cases,  brine  about  complete  recovery.  Further- 
more, following  operative  procedure,  these  measures  can  help  much 
to  hasten  recovery  and  prevent  a  recurrence. 

In  dealing  with  an  abdominal  recti  diastasis,  the  aim  should  be 
towards  improving  the  two  recti  muscles.     Massage  and  simple  leg 


EXERCISE    AND    MASSAGE  507 

raising  with  patient  in  supine  position,  will  accomplish  this.  The 
exercise  is  to  be  done  15  to  20  times  three  times  daily,  with  ex- 
halation during  contraction. 

In  acquired  inguinal  hernia  the  desideratum  is  to  strengthen  the 
two  abdominal  oblique  and  transversalis  muscles.  Also,  as  Me- 
Kenzie  puts  it,  "To  cultivate  alertness,  control,  and  self-conscious- 
ness in  these  muscles,  thus  causing  them  to  respond  instantly  and 
automatically  to  any  sudden  strain  that  may  be  thrown  upon  them.*' 
This,  he  says  can  best  be  done  by  exercise  of  twisting  and  bending 
of  the  trunk  and  by  forced  breathing,  raising  the  chest  high,  thus 
drawing  up  the  abdominal  contents  and  relieving  downward  pres- 
sure. "In  the  movements  of  straight  flexion  of  the  trunk  the 
rectus  muscle  only  is  employed  at  the  beginning  and  the  relaxed 
oblique  muscles  are  distended,  forming  two  distinct  pouches  or 
weakened  areas  over  the  lower  abdomen,  and  by  the  time  they  con- 
tract in  self-protection  the  mischief  may  have  been  done." 

A  caution  which  must  be  observed  is  to  support  the  dilated  ring 
with  (a)  the  finger,  (b)  a  proper  fitting  truss.  Also  to  always 
avoid  sudden  and  severe  strain  with  holding  of  breath,  and  long 
standing  position.  With  such  precautions  patients  may  be  allowed 
almost  all  kinds  of  nonviolent  games,  like  tennis,  golf,  bowling, 
dancing,  swimming  and  canoeing.  Contraindicated  are  football,  the 
weight  events,  field  competition,  and  .jumping.  Bicycling  is  cham- 
pioned by  Lucas  Championniere.  "Working  with  Dr.  Seaver,  at 
Yale,  the  writer  has  witnessed  his  patients  performing  all  the  or- 
dinary gymnastic  "stunts"  which  college  students  like  to  indulge 
in  with  no  untoward  results.  His  percentage  of  cures  of  acquired 
hernia  by  means  of  exercise  and  massage  was  well  over  the  seventy 
per  cent  mark. 

AlcKenzie  prescribes  a  more  conservative  method  of  gymnastics 
as  follows: 

Exercise  1:  Patient  lying  on  back.  Place  one  hand  across  ab- 
domen, the  other  protecting  the  ring.  Inhale  deeply.  Exhale  by 
pressing  the  abdominal  wall  until  voluntary  contraction  has  been 
acquired,  when  this  movement  can  be  done  without  placing  the 
hands  over  the  abdomen. 

Exercise  2:  Patient  lying  on  back,  one  hand  across  the  abdomen, 
the  other  protecting  the  ring.  Inhale  and  exhale  without  drawing 
in  the  abdomen.  In  this  way,  control  of  the  abdominal  wall  is 
obtained,  while  the  hernia  is  protected  by  placing  the  fingers  over 
the  external  ring.     In  most  patients  it  is  possible  to  teach  them  in 


508  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

one  or  two  seances  how  to  find  the  external  ring  and  how  to  protect 
it  in  the  various  exercises. 

Exercise  3 :  Patient  lying  on  hack,  right  hand  behind  the  neck, 
the  left  hand  covering  the  external  ring.  Eaise  the  head  and  shoul- 
der, twisting  in  the  opposite  direction  from  the  hernia  to  the  right. 
In  this  way  the  oblique  muscles  of  the  affected  side  are  put  into 
strong  contraction,  but  if  the  movement  be  symmetric,  the  rectus 
alone  will  receive  the  strain. 

Exercise  4:  Patient  lying1  on  back,  external  ring  protected. 
Without  bending  the  knees  raise  body  from  the  lying  to  the  sitting 
position,  with  the  shoulders  twisted  so  that  the  shoulder  of  the 
affected  side  is  forward. 

Exercise  5:  Massage,  consisting  of  circular  kneading  movement. 
beginning  at  the  external  abdominal  ring  and  passing  upward  and 
outward  to  the  anterior  superior  spine. 

Flat  Feet. — When  we  recall  the  physiologic  fact  that  prolonged 
rest  causes  muscular  weakness  and  that  muscular  weakness  is  the 
primary  cause  of  fiat  feet,  we  find  justification  in  discussing  exer- 
therapy  at  this  time.  Flat  feet  may  be  caused  by  paralysis 
or  trauma,  but  in  the  great  majority  of  cases  it  is  the  result  of  a 
disturbance  of  the  soft  tissue  mechanism  of  the  foot  in  consequence 
of  a  variety  of  causes  tending  towards  a  weakening  of  the  sup- 
porting longitudinal  arch  of  the  foot.  Prominent  among  these  are 
wasting  diseases,  especially  of  an  infectious  nature;  lack  of  muscu- 
lar development  or  lack  of  exercise;  faulty  walking  or  standing; 
and  ill  fitting  and  incorred  s; 

Many  gynecologists  are  awake  to  the  debilitating  effect  of  the 
the  puerperium  on  the  general  musculature.  What  is  true  of  the 
puerperium  is  equally  true  of  typhoid  fever  and  other  conditions 
which  compel  patients  to  a  long  siege  of  muscular  inactivity.  A 
good  surgeon  will  look  further  than  the  immediate  repair  of  an 
injury,  and  will  consider  the  future  welfare  of  his  patient.  The 
modern  obstetrician,  for  instance,  considers  the  future  of  his  pa- 
tient with  reference  to  bodily  outline  and  poise  as  well  as  health. 
and  begins  muscle  training  for  feet  and  posture  at  the  earliest  pos- 
sible date  following  confinement.  Grossman  and  Gellhorn  have 
pointed  this  out  with  special  reference  to  the  feet.  Therefore,  in 
the  after-treatment  of  patients  long  bedridden,  it  would  seem  wise 
to  institute  simple  measures  which  would  tend  to  save  the  patient 
future  suffering.  Exercise  and  proper  massage,  particularly  knead- 
ing and  friction  of  the  feet  are  indicated. 


EXERCISE   AND    MASSAGE  509 

The  problems  associated  with  the  question  of  flat  feet  are  many 
and  find  discussion  elsewhere  in  this  volume.  The  treatment  in  all 
cases,  however,  aims  at  the  restoration  of  the  architecture  of  the 
foot  and  the  muscles  and  ligaments  holding  it  in  position.  In  so 
far  as  the  latter  is  concerned,  physical  therapy  may  play  a  most 
important  part  in  the  treatment. 

All  cases  should  first  be  thoroughly  heated  to  promote  the  circula- 
tion and  make  the  massage,  which  is  to  follow,  more  effective. 
This  heating  may  be  done  by  means  of  the  hot  foot  bath  (100°  to 
105°)  for  15  minutes,  or  by  a  gas  or  electric  light  heated  appara- 
tus. 

The  peronei  spasm  and  pain  may  be  relieved  by  the  above  men- 
tioned heating  process  or  by  hot  fomentations  applied  twice  a  day. 
The  foot  should  next  be  forcibly  adducted,  inverted  and  dorsoflexed 
which  may  be  done  by  the  operator  or  by  the  patient  himself  using 
his  knees  as  a  fulcrum.  Massage,  particularly  kneading  and  per- 
cussion, will  frequently  relieve  spasm;  when  this  method  fails, 
however,  forcible  stretching  under  an  anesthetic  must  be  resorted 
to. 

The  circulation  will  be  improved  by  the  preliminary  heating  and 
massage  and  may  be  further  enhanced  by  the  Scotch  douche  ap- 
plied twice  daily.  Hot,  105°  to  110°,  for  two  minutes;  cold  for  one- 
half  minute. 

Exercise. — Passive  movements  should  only  be  used  to  secure  free 
mobility  and  should  involve  all  possible  motions  of  a  normal  joint. 

Resistive  exercises  may  be  done  in  all  directions  save  eversion 
and  abduction,  which  is  true  also  of  active  movements.  "We  see  no 
valid  reason  why  these  should  ever  be  used  at  all.  It  is  neverthe- 
less frequently  prescribed  in  the  exercise  of  complete  circumduc- 
tion. Eversion  and  abduction  tend  to  aggravate  the  condi- 
tion of  fallen  arch  and  also  bring  into  strong  contraction 
the  powerful  peroneus,  a  muscle  which  is  generally  found  spastic 
and  overworked  in  these  foot  affections.  We  must  guard  against 
the  tendency  of  overdevelopment  of  this  muscle  as  compared  with 
its  antagonistic  group,  the  adductors.  We  are  also  of  the  opinion, 
which  is  shared  by  others,  that  excessive  heel  raising,  particularly 
in  the  more  advanced  type  of  flat  foot  is  harmful  because  of  the 
additional  strain  which  this  exercise  places  on  the  already  stretched 
plantar  ligament.  It  will  also,  in  the  standing  position,  bring  into 
powerful  contraction  the  peroneus  longus  which  we  believe  not  to 
be  desirable. 


510 


AFTER-TREATMEXT    OF    SURGICAL    PATIEXTS 


We  use  the  following  series  of  exercise  in  the  Mechano  Therapy 
Department  of  the  "Washington  University  Medical  School. 

1.  Resistive  movements  in  direction  of  adduction,  inversion  and 
toe  reflexion. 

2.  Standing  position  with  feet  crossed  close  together  and  paral- 
lel with  each  other.    Exercise,  alternately  raise  right,  then  left  foot 


Fig.    179. — Illustrating  flat   foot   exercise    No.    3.      Starting  position.    Dorsoflexion. 


Fig.    180.    -Second    position    exercise    No.    3.      Complete    extension   avoiding   abduction    of   foot. 


Fig.    181. — Extreme    inversion,    then    bringing    foot    back    to    starting    position    (Fig.    179),    re- 
taining during  the  movement  inversion  of  foot  and  flexion  of  toes. 


off  floor  one  inch  and  hold  this  position  for  one  minute.     Each  foot 
five  times. 

3.  Sitting  on  chair  with    knees   crossed   or   legs   extended   place 
foot  in  (a)  extreme  dorsoflexion,  using  this  as  a  starting  position; 


EXERCISE    AND    MASSAGE  511 

(b)  foot  extension  with  strong  effort  at  toe  flexion;  (c)  return  to 
starting  position  (a)  with  extreme  inversion  of  foot.  (Figs.  179, 
180  and  181.) 

4.  "The  forefoot  is  placed  upon  the  end  of  a  towel,  and  in 
adducting,  the  toes  are  to  grasp  the  towel,  pulling  it  toward  the 
inside.  By  repeating  these  motions  a  number  of  times  the  whole 
length  of  the  towel  is  moved  under  the  foot,  the  knee  and  heel  being 
at  the  same  time  not  removed  from  the  spot.  In  placing  weights 
of  increasing  size  on  the  outer  end  of  the  towel  the  resistance  can 
be  increased  to  any  amount  desired.  After  this  exercise  has  been 
thoroughly  practiced  in  sitting  without  weight-bearing  it  should 
be  taken  up  in  standing." — Bucholz. 

5.  In  selected  cases,  we  add  balancing  exercises,  dancing  and 
games. 

These  exercises  should  be  practiced  until  fatigue  sets  in  and  re- 
peated two  or  three  times  a  day. 

Joint  Disturbances. — Sprains  and  Dislocations. — The  part  which 
exercise  or  massage  plays  in  the  treatment  of  sprains  is,  in  many 
ways,  identical  with  that  of  a  reduced  dislocation.  In  cases  of  rup- 
ture of  the  muscular  attachments  or  ligaments  about  a  joint,  there 
follows  more  or  less  swelling,  pain  and  limitation  of  motion.  If 
seen  soon  after  the  accident  the  application  of  proper  pressure 
bandages  will  do  much  to  promote  the  absorption  of  the  existing 
effusion  and  also  act  as  a  splint  to  support  the  injured  parts.  To 
further  promote  this  absorption,  deep  stroking  massage  in  the  di- 
rection of  the  venous  flow  will  be  found  very  helpful.  This  is  also 
true  of  deep  and  rapid  vibration,  either  manually  or  by  means  of  a 
vibrating  machine,  if  applied  directty  over  the  seat  of  localized 
swelling.  After  a  time  passive  and  active  exercises  are  indicated, 
provided  the  injured  soft  part  can  be  held  in  close  apposition  by 
a  splint  bandage.  The  beneficial  effect  of  massage  and  exercise  will 
be  to  reduce  the  swelling  by  hastening  the  venous  flow,  thus 
causing  a  rapid  absorption  of  the  effusion  and  to  that  extent  the 
prevention  of  fibrous  adhesions. 

Motion  to  an  injured  joint  is  contraindicated  where  separation 
of  the  injured  parts  can  not  be  prevented  by  bandages,  thus  neces- 
sitating total  immobilization.  This  does  not  apply,  however,  to 
healthy  distal  joints  of  the  same  limb  where  motion  should  be 
encouraged,  thus  preventing  the  organization  of  the  hematoma 
and  other  exudations  into  fibrous  adhesions.  There  will  also  be 
present  muscle  spasms  with  pain,  and  possibly  retraction  of  mus- 
cles together  causing  joint  stiffness.    There  may  come  a  time  when 


512 


AFTER-TREATMENT    OF    SURGICAL   PATIENTS 


adhesions  will  have  to  be  broken  down  and  there  seems  to  be  a 
right  and  a  wrong  time  for  doing  this.  At  the  beginning  the  new 
tissue  is  rich  in  new  blood  vessels  which  are  readily  torn  by  move- 
ments, causing  more  bleeding,  more  effusion  and  more  adhesions. 
At  this  stage  passive  motion  should  not  be  given.  Active  exercise, 
however,  is  indicated  to  the  point  of  producing  pain.  This  apparent 
confliction  can  be  explained  by  the  fact  that  active  exercise  is 
under  control  of  the  will  of  the  patient  while  passive  motion  is  not. 
It  is  quite  unlikely  that  the  patient  will  carry  the  motion  beyond 
the  point  producing  pain,  and  therefore  the  chance  of  tearing  the 


Fig.   1S2. — Passive   stretching  of  the  arm   and   shoulder  with   scapular   fixation.      Breaking  ad- 
hesions in  case  of   Sub-Deltoid    Bursitis. 

newly  formed  tissue  is  very  small.  Passive  motion,  on  the  other 
hand,  mighl  be  carried  beyond  this  point.  We  thus  have  a  phys- 
iologic index  guiding  us  in  the  proper  dosage  of  motion  in  these 
conditions.  Massage  above  the  seat  of  injury  and  repeated  hot  and 
cold  douches  should  not  be  neglected. 

It  is  unwise  to  Avail  too  long  before  prescribing  motion. 
Prolonged  immobilization  causes  the  cicatrix  to  become  firm  and 
stiff,  so  much  so  that  very  frequently  they  can  only  be  broken  under 


EXERCISE    AND    MASSAGE  513 

a  general  anesthesia.  If  this  should  become  necessary,  then  mas- 
sage and  active  exercise  should  be  encouraged.  The  exercise  should 
include  all  possible  motions  of  the  joint. 

In  breaking  down  adhesions  manually  we  choose  the  period  im- 
mediately following  the  acute  stage,  when  swelling  and  pain  have 
entirely  disappeared.  We  then  employ  complete  passive  motion  in  all 
directions  daily,  preceded  by  preliminary  heating  and  followed  by 
stimulating  massage  above  and  below  the  seat  of  injury.  If  no  ad- 
ditional tenderness  develops,  more  motion  is  applied  and  deep  fric- 
tional  massage  is  added  to  the  treatment.     (Fig.  182.) 

Early  Functional  Treatment  of  Fractures. — This  method  of  treat- 
ing fractures  was  first  practiced  by  Lucas  Championniere  of  France, 
and  Bennett  of  England,  and  has  found  a  large  number  of  adherents. 
It  is  founded  on  the  principle  that  restoration  of  function  is  equally 
desirable  with  that  of  bony  union  and  should  therefore  receive  equal 
attention  in  the  treatment  prescribed.  It  is  an  unfortunate  fact 
that  a  very  large  percentage  of  fractures,  especially  near  joints, 
are  finally  left  with  badly  restricted  joint  function  and  pain,  almost 
always  due  to  prolonged  immobilization.  The  surgeon  in  each  case 
treated  the  condition  entirely  from  the  viewpoint  of  attaining  bony 
union,  leaving  the  question  of  function  solely  to  chance.  Some  one 
has  said  that  it  is  far  better  to  have  a  poor  union  with  a  good  joint 
function,  than  a  perfect  union  with  impaired  function,  and  that  in 
a  great  number  of  Colles'  fractiires  far  greater  damage  has  been 
done  the  patient  by  the  treatment  than  by  the  injury  itself. 

In  all  cases  the  desideratum  should  be  a  good  union  and  fully 
restored  function.  Advocates  of  the  early  functional  treatment 
believe  that  by  proper  splinting  and  proper  manipulations  this  can 
be  accomplished  in  a  far  greater  number  of  cases  than  without  the 
manipulations.  The  fact  that  muscles  and  joints  may  be  moved  with- 
out injury  to  the  opposing  fragments  has  long  been  overlooked  by 
many,  and  the  fact  that  in  delayed  union  very  slight  motion  of  the 
fragments  has  proved  to  be  beneficial  must  also  be  new  to  them. 
Yet  this  is  claimed  by  many  surgeons  today. 

If  a  fracture  occurs  near  or  into  a  joint  the  problems  involved 
are  (a)  the  possible  organization  of  extravasated  fluid  into  fibrous 
adhesions  causing  limitation  of  motion;  (b)  the  passive  venous  con- 
gestion retarding  absorption  and  repair  processes ;  (c)  muscle  spasm 
and  pain  interfering  with  the  aim  to  hold  the  fragments  in  close 
apposition,  besides  causing  great  discomfort  to  the  patient;  (d) 
retraction  of  muscles  leading  frequently  to  contractures.  A  stiff 
joint  may  follow  a  fracture  of  the  middle  third  of  a  long  bone  as 


514  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

illustrated  by  a  case  reported  by  Bennett.  "Fracture  of  both  bones 
three  inches  above  the  ankle  two  months  previous  to  present  ob- 
servation. Fragments  firmly  united,  good  position,  no  motion  be- 
yond a  little  'springing'  in  the  ankle  joint  could  be  produced. 
P.M.  showed:  (a)  Ant.  Tibialis  was  firmly  adherent  to  the  bone, 
(b)  The  muscle  structures  at  posterior  aspect  of  fracture  had  to 
be  torn  and  were  matted  to  the  bone  by  cicatricial  tissue,  involving 
the  Post.  Tib.  nerve,  (c)  After  each  structure  had  been  dissected 
off  the  bone  the  ankle  joint  could  be  freshly  moved." 

Eeasons  for  massage  and  exercise  in  fracture  treatment  are : 

(a)  Movements  of  tendons  through  the  area  of  swelling  would 
prevent  matting  of  these  sofl   tissues. 

(b)  The  increased  arterial  blood  flow  would  displace  the  venous 
congestion,  hasten  absorption  of  extravasated  fluid  and  promote 
repair  processes  of  bone  and  ligaments. 

(c)  Exercise  would  tend  to  maintain  endurance  and  power  of 
muscles  and  prevent  retraction. 

(d)  Pain  and  spasm  would  be  materially  reduced  by  massage 
aiding  thereby  bony  consolidation  and  improving  the  general  wel- 
fare of  the  patient. 

(e)  The  joint  would  be  kept  supple  and  retain  its  normal  mo- 
bility. 

(f)  Patient's  period  of  incapacitation  would  be  materially  re- 
duced. Caution  must  be  exercised  in  applying  this  treatment.  There 
can  be  no  question  that  harm  may  be  done  by  the  improper  use 
of  massage  and  exercise.  We  must  always  remember  the  advantages 
gained  by  primary  union.  We  are  told  that  scars,  the  result  of 
early  union,  are  firmer,  less  painful  and  Less  liable  to  disease  than 
scars  of  delayed  union.  Our  treatment,  therefore,  aims  to  keep 
the  torn  ends  of  ligaments  and  tendons  together  and  yet  encourage 
those  things  which  will  promote  repair  processes  and  retain  normal 
function.  Massage  and  exercise,  we  believe,  are  therefore  indicated 
in  such  cases  where  adhesive  and  other  bandages  and  splints  will 
prevent  the  separation  of  the  torn  ends.  To  illustrate  our  thought: 
A  sprain  of  the  ankle  tearing  the  external  lateral  ligament.  Apply 
pressure  bandage  over  seat  of  swelling  and  begin  stroking  mas- 
sage over  injury.  Next  day,  if  greater  part  of  swelling  has  sub- 
sided use  alternate  ho1  and  cold  foot  baths  each  four  times,  to 
promote  circulation.  Continue  massage  above  seat  of  injury  and 
firmly  strap  foot  in  eversion.  Passive  motion  to  all  toes.  After 
three  to  four  days,  add  flexion  and  extension  of  foot.  If  bandage 
is  properly  applied  this  motion  need  not   interfere  with   the  torn 


EXERCISE    AND    MASSAGE  515 

ends.  If  on  the  other  hand,  there  exists  with  this  condition  a  frac- 
ture, then  the  question  of  motion  depends  on  the  possibility  of  suffi- 
ciently supporting  the  fragments  to  allow  ankle  motion.  Massage 
and  exercise  of  toes  should,  however,  he  encouraged.  (Fig.  183.) 
Paralysis. — (I)  Anterior  Poliomyelitis. — It  is  the  practically  un- 
divided opinion  of  the  men  who  have  studied  this  disease  that 
absolute  rest  is  essential  during  the  first  stage,  that  is,  until  all 
tenderness  has  disappeared.  Massage,  exercise  or  electricity  tend 
only  to  further  irritate  the  diseased  nerve  roots.  During  the  second 
stage  these  measures  constitute  the  most  important  phase  of  the 
active  treatment;  the  passive  are  equally  important,  aiming  to  pre- 
vent deformities  by  means  of  braces.  The  first  consideration  is 
to  plan  all  active  treatment  with  a  view  of  getting  the  patient  on 
his  feet  as  soon  as  possible,  not  for  one   minute,  however,   losing 


Fig.    1S3. — Thumb    kneading    and    draining    of    a    Colles'    fracture. 

sight  of  the  fact  that  the  kind  and  dosage  of  exercise  employed  is 
highly  essential.  Much  harm  has  been  done  the  patient  in  the 
past  by  overstimulating  and  overexercising  the  weak  and  atrophied 
muscles.  Each  individual  or  group  of  muscles,  if  possible,  should 
first  be  carefully  examined  and  tested  as  to  strength  and  capacity. 
Then  daily  exercise,  approaching  the  active  type,  should  be  pre- 
scribed. Active  because  it  is  essential  to  develop  the  neuromuscular 
system  and  not  merely  a  muscle.  For  this  reason  passive  exercise 
and  movements  by  various  types  of  apparatus  are  much  less  effec- 
tive as  a  whole,  stimulating  nutrition  of  the  muscle  but  not  voli- 
tional movements.  At  first  it  may  be  necessary  to  perform  the 
movements  passively,  but  every  means  should  be  used  to  stimulate 
and  encourage  the  patient  to  help  the  movements  by  concentrating 
his  attention  on  it.     Each  movement  should  be  carried  out  to  its 


516 


AFTF.R-TREATMKXT    OF    SURGICAL    PATIENTS 


physiologic  limit.  As  soon  as  the  patient  is  able  to  perform  1he 
movement  actively  or  partly  so,  passive  movements  should  cease, 
but  the  active  movements  must  be  assisted  by  the  nurse,  so  as  to 
avoid  overtiring  the  muscle,  until  the  patient  can  perform  the  ex- 
ercise without  assistance.  As  soon  as  this  can  be  done  with  ease, 
then  resistance  may  be  offered  on  the  part  of  the  nurse.  Great 
care  must  be  used  not  to  work  the  muscle  beyond  the  point  of  mild 
fatigue.  To  recapitulate,  the  aim  should  be  (a)  to  have  the  patient 
perform  active  exercise,  (b)  to  get  it  to  walk  as  soon  as  possible, 
and  (c)  to  avoid,  by  all  means,  overexercising. 

The  nutrition  of  the  muscle  can  be  greatly  benefited  by  daily 
mild  massage,  heating  by  means  of  a  dry  air  or  electric  light  heat- 
ing apparatus  and  the  alternate  hot  and  cold  baths  to  the  affected 
limbs. 

Lovett  and  Martin  point  out  the  importance  of  professional  su- 
pervision of  the  exercise  treatment.  They  found  "that  the  chance 
of  improvement  in  affected  but  not  totally  paralyzed  muscles  under 
expert  treatment  by  muscle  training  was  about  6:1;  under  super- 
vised home  exercise  3.5:1;  under  home  exercises  without  su- 
pervision 2.8:1.  Untreated  muscles  showed  an  improvement  ratio 
1.9:1."  We  can  at  this  time  do  no  better  than  refer  the  reader 
to  the  chapter  on  muscle  training  by  Lovett. 

II.  Other  Form.-:  of  Flaccid  Paralysis. — The  particular  indications 
are  as  follows: 

(a)  To  maintain  and  improve  the  nutrition  of  the  muscle.  This 
is  accomplished  by  means  of  radiant  heat,  deep  kneading  and 
stroking  massage,  and  tonic  hydriatic  procedures. 

(b)  Prevent  contractures  by  means  of  proper  braces,  shoes,  and 
daily  stretching. 

(c)  Measures  which  will  stimulate  the  general  nervous  system, 
for  which  purpose  Ave  use  the  hacking  and  percussion  movements 
of  tapotement  and  vibration;  also  the  Scotch  spinal  douche. 

(d)  Restore  the  continuity  of  the  impaired  motor  and  sensory 
paths.  This  can  only  be  brought  about  by  voluntary  exercises 
which  are  directed  by  the  will  of  the  patient.  Massage,  electricity, 
passive  motion  or  motion  caused  by  a  mechanical  apparatus  can 
not  in  our  opinion  perform  this  function.  In  order  to  achieve  the 
best  results,  various  methods  may  be  employed,  which,  because  of 
their  varying  character,  tend  to  stimulate  a  better  cooperation  of 
patient  and  nurse.  This  procedure  applies  of  course  only  to  cases 
of  partial  paralysis. 


EXERCISE    AND    MASSAGE  517 

1.  The  patient  is  induced  to  imitate  the  movements  of  the  opera- 
tor, choosing  at  first  the  easier  arm  or  leg  movements  and  ad- 
vancing to  the  finer  finger  or  toe  movements.  This  may  frequently 
be  done  in  connection  with  simple  finger  plays  and  games. 

2.  Exercises  following  definite  commands.  Besides  their  physi- 
ologic effect  they  are  of  a  decided  educational  value  which  has  a 
direct  bearing  on  the  complete  restoration  of  the  neuromuscular 
complex.  They  awaken  "numerous  sensory  and  motor  perceptions, 
clear  cut  and  well  defined  regarding  distance,  direction,  weight, 
force,  resistance  and  effort  which  might  otherwise  remain  dim  and 
vague." 

3.  Stimulating  initiative  by  means  of  various  games  and  plays 
particularly,  if  conditions  allow  it,  in  company  with  other  children. 
In  a  gymnasium  class,  drills,  marching  and  dancing  are  excellent. 
The  balance  board  and  wall  ladders  are  very  useful  apparatus  if 
available.  It  is  a  good  plan  to  have  both  limbs,  the  sound  and 
paralyzed  work  together,  e.g.,  with  wands,  hoops,  basket  ball,  etc., 
or  let  the  sound  limb  perform  first,  the  other  following.  An  un- 
limited fund  of  patience  must  be  at  the  command  of  the  operator 
who  conducts  the  work,  for  very  frequently  weeks  and  weeks  go 
by  without  any  sign  of  improved  function.  The  patient  too  gets 
restless  and  impatient  and  his  efforts  become  rather  feeble,  but, 
unless  the  nerve  is  entirely  destroyed,  oftentimes  repeated  volun- 
tary exercises,  even  if  weak,  will  definitely  aid  in  repairing  the 
damaged  motor  tract  and  restoring  motion. 

727.  Sjjasfic  Type  (a). — Here  also  the  essential  factor  in  the  plan 
of  treatment  is  voluntary  active  exercise,  particularly  that  type  involv- 
ing the  element  of  skill.  The  plan  noted  above  may  well  be  followed 
in  these  cases.  In  addition  there  is  the  problem  of  spasticity  which 
is  present  so  frequently  in  a  most  distressing  fashion.  The  measures 
which  may  be  tried  for  the  relief  of  this  condition  are  sedative 
massage,  like  slow  deep  kneading  or  vibration,  either  locally  by 
means  of  a  portable  apparatus  or  generally  by  using  the  vibratory 
chair.  AVe  have  found  this  latter  to  be  of  real  comfort  in  all  of 
our  spastic  cases.  Other  useful  measures  are  radiant  dry  heat, 
hot  fomentations  or  neutral  baths  for  an  hour  or  more  at  95°. 

IV.  Paralysis  Agitans  (&). — The  prognosis  is,  as  much  as  we  know 
today,  almost  hopeless.  Attention  should  be  directed  toward  mak- 
ing the  patient  comfortable.  In  the  line  of  physical  measures  we 
have  tried  massage,  exercise,  neutral  baths  and  vibration  with  vary- 
ing results.  We  have  found,  for  instance,  that  the  vibratory  chair 
has  given  the  patient  comfort  when  all  other  measures  failed  and 


518  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

we  also  found  that  local  vibration  increased  the  tremor  of  another 
patient  to  an  alarming  extent.  We  have  achieved  our  best  results 
with  a  sedative  massage  followed  by  a  neutral  douche.  The  type 
of  massage  we  use  is  the  slow,  deep,  long  kneading  motion  cen- 
tripetally  applied,  avoiding  very  carefully  any  stimulating  reac- 
tion. 

Bibliography 

Bennett:     Massage  in  Fractures,  Lancet,  London,  Feb.,  1898,  p.  361. 

Bolin:     Gymnastic    Problems,   New    York,  F.  A.   stokes  &   Co. 

Bowin   and    MeKenzie:      Applied    Ajiatomy    and    Kinesiology,    Philadelphia,   Lea 

and   Febiger. 
B'ucholz:     Therapeutic  Exercise  and   Massage,  Philadelphia,   Lea  and   Febiger. 
Cohen:      Physiologic  Therapeutics,    Philadelphia,    P.   Blakiston's  Son  &  Co. 
Cryiax:     The  El-em  ats  of  Kellgren's  Manual  Treatment,  New  York,  Wm.  Wood 

&  Co. 
Ewerhardt:     Gymnastics  in  Relation  to  Crippled  Children,  Am.  Physical  Educa- 
tion  Rev.,  Nov.,  1914. 
Frenkel:      Tabetic    Ataxia.   Philadelphia,   P.   Blakiston's   Son    &   Co. 
Graham:     Massage,   Philadelphia,  J.   B.  Lippincotl   Co. 
Jones:     Injuries  to  Joints,   New   York,  Oxford    University   Press. 
Kellogg:     The  Art  of  Massage,  Battle  Creek,  Mich.,  Modern  Medicine  Publishing 

Co. 
Lovett:  Treatment  of  Infantile  Paralysis,  Philadelphia,  P.  Blakiston's  Son  &  Co. 
Lovetl    and    Martin:      Certain   Aspects   of   Infantile    Paralysis,   Jour.   Am.    Med. 

Assn.,   1916,  p.  729. 
MeKenzie:      Exercise  in   Education  and    Medicine,   Philadelphia,  W.   B.  Saunders 

Co. 
Nanerede:     Principles  of  Surgery,    Philadelphia,   W.   B.  Saunders  Co. 
Nissen:   Practical  Massage  and  Corrective  Exercise,  Philadelphia,  F.  A.  Davis  Co. 
O'Reilley:     Unpublished  paper  on  flal   feet. 
Starling:     On  the    Physiological    factors   Involved    in   the   Causation    of   Dropsy, 

Lancet,    London.    May  9,    L896. 
Wide:      Medical  and   Orthopedic  Gymnastics,   New   York,  Funk  &   Wagnalls  Co. 
Heart  Affections  in  Soldiers,  Brit.  Med.  Jour.,  Sept.  1916,  p.   Ms. 
On  Repair  of  Fractures,   Interstate  Med.  .loin..   L909,   No.    L6,  p.  63. 


CHAPTER  LII 

HYDROTHERAPY 
By  F.  H.  Ewerhardt,  St.  Louis,  Mo. 

Water  owes  its  value  as  a  therapeutic  agent  chiefly  to  its  power 
to  (a)  absorb  and  communicate  heat;  (b)  the  facility  in  which 
it  may  be  changed  from  a  solid  to  a  liquid  to  a  gaseous  state;  (c) 
its  property  as  a  solvent  agent,  and  (d)  its  adaptability  to  various 
methods  of  application. 

"We  speak  of  the  action  of  cold  upon  the  human  bod}'  as  being 
a  depressant,  all  the  vital  functions  being  lessened  in  their  degree 
of  activity.  If,  however,  this  application  is  a  short  one,  it  is  fol- 
lowed by  a  reaction  which  is  tonic  or  stimulating  in  nature.  The 
explanation  of  this  phenomenon  is  found  in  the  fact  that  the  body 
recognizes  cold  as  a  depressing  agent  and  attempts  to  meet  the 
emergency  by  quickly  producing  more  heat,  the  thermic  reaction; 
this  manifests  itself  by  causing  a  rush  of  blood  to  the  periphery, 
the  circulatory  reaction,  which  in  turn  is  followed  by  a  tingling 
of  the  nerves,  the  nervous  reaction.  Together  they  are  spoken  of  as 
the  tonic  reaction  following  an  application  of  cold  to  the  body. 
If  this  reaction  does  not  manifest  itself  in  its  various  phases  the 
cold  bath  must  be  modified  to  a  lower  degree  of  intensity  or  dis- 
continued. There  are  various  agencies  which  may  be  employed 
before  the  bath  which  will  aid  the  bringing  about  of  a  reaction  the 
most  essential  being  warmth  of  body.  In  fact  cold  should  never  be 
applied  to  the  whole  body  when  the  skin  is  cold.  This  warmth  of 
body  may  be  secured  by  clothing  or  covering,  hot  water,  dry  heat, 
exercise,  friction,  hot  drinks  or  hot  enema.  During  the  bath  fric- 
tion and  slapping  may  be  employed  while  following  the  bath  any 
of  the  measures  used  before  the  bath  are  indicated. 

Cold  baths  are  contraindicated  in  old  age,  infancy,  extreme  ex- 
haustion, either  muscular  or  nervous ;  in  obesity  with  severe  anemia, 
cold  or  clammy  skin  or  extreme  aversion  to  cold  baths. 

A  short  application  of  heat  is  another  stimulating  agent,  but  its 
reaction  is  atonic  in  nature.  Prolonged  heating  measures  are  de- 
pressing, leaving  the  individual  in  a  relaxed,  atonic,  languid  state 
of  feeling.    To  recapitulate :  the  application  of  cold,  short,  is  stimu- 

519 


520  AFTER-TREATMENT    OP    SURGICAL    PATIENTS 

lating,  reaction  is  tonic;  heat,  short,  is  stimulating,  reaction  atonic; 
cold  or  heat  prolonged  are  depressing. 

In  introducing  cold  tonic  baths  care  must  be  exercised  in  begin- 
ning with  a  mild  form  and  graduating  to  the  more  severe  ones, 
e.  g.,  (1)  cold  mitten  friction,  (2)  wet  sheet  rub,  (3)  salt  glow,  (4) 
shallow  bath,  (5)  cold  douche,  and  (6)  Scotch  douche  (see  page 
531). 

Reflex  Effects 

Every  portion  of  skin  surface  is  in  special  reflex  relations  with 
some  internal  organ  or  vascular  area.  The  vessels  may  be  caused 
to  contract  or  dilate  according  as  the  application  is  hot  or  cold, 
short  and  intense  or  long  and  moderate.  As  examples  may  be  cited 
the  following,  practiced  by  Abbott,  Kellogg,  Winternitz  and  others: 

Special  Reflex  of  Prolonged  Cold. — 1.  Cold  applied  over  the  trunk 
of  an  artery  causes  contraction  of  the  artery  and  of  its  distal 
branches.  Example:  ice-bags  applied  over  the  carotid  arteries  de- 
crease the  blood  going  to  the  brain  and  head  generally.  Such 
an  application  is  called  a  proximal  application. 

2.  Prolonged  immersion  of  the  hands  in  cold  water  causes  con- 
traction of  the  vessels  of  the  brain  and   nasal  mucous  membrane. 

3.  Prolonged  cold  to  the  upper  dorsal  region  causes  contraction 
of  the  vessels  of  the  nasal  mucous  membrane. 

4.  An  ice-bag  applied  to  the  precordia  slows  the  heart  rate,  in- 
creases its  force,  and  raises  arterial  blood  pressure. 

5.  An  ice-bag  applied  over  the  thyroid  gland  (in  parenchymatous 
goiter),  decreases  its  vascularity  and  lessens  its  glandular  activity. 

6.  An  ice-bag  to  the  epigastrium  or  mid-dorsal  region  causes  con- 
traction of  the  vessels  of  the  stomach,  and  lessens  gastric  secre- 
tion while  the  application  continues. 

7.  Long  cold  applications  to  the  face,  forehead,  scalp  and  back 
of  the  neck  cause  contraction  of  the  blood  vessels  of  the  brain. 

8.  Ice-bags  applied  to  the  sides  of  the  neck  just  below  the  angle 
of  the  jaw  contract  the  blood  vessels  of  the  pharynx. 

Special  Reflex  Effect  of  Short  Cold. — Short  cold  applications  to 
a  reflex  area  produce  tonic  and  stimulating  effects  in  the  deep  part 
by  virtue  of  the  reaction  which  soon  follows: 

1.  Short  cold  applications  to  the  face  and  head  stimulate  mental 
activity. 

2.  A  short  cold  application  to  the  chest,  as  a  cold  rub,  friction, 
or  cold  douche,  at  first  increase  the  respiration  rate.  Soon  it  re- 
sults in  deeper  respiration  with  a  spmewhal  slowed  rate. 


HYDROTHERAPY  521 

3.  A  cold  douche  to  the  precordia  or  slapping  the  chest  with  a 
cold  towel,  increases  both  the  heart  rate  and  force.  After  the 
cessation  of  the  application,  the  rate  decreases  while  the  force  re- 
mains increased. 

4.  Short  very  cold  applications  to  the  abdomen,  hands,  or  feet 
cause  contraction  of  the  muscles  of  the  bladder,  bowels  and  uterus. 

5.  A  short  very  cold  douche  to  the  liver  causes  dilatation  of  its 
vessels,  and  increase  its  glandular  activity. 

6.  The  reaction  from  a  moderately  prolonged  cold  application 
to  the  epigastrium  causes  increased  gastric  secretion. 

Special  Reflex  Effects  of  Hot  Applications. — 1.  A  very  much  pro- 
longed hot  application  to  a  reflex  area  produces  passive  dilatation 
of  the  blood  vessels  of  the  related  organ. 

2.  Long  hot  applications  to  the  precordia  and  to  many  other 
parts  increase  the  heart  rate,  decrease  its  force,  and  lower  the 
blood  pressure. 

3.  Hot,  moist  applications  to  the  chest  facilitate  respiration  and 
expectoration. 

4.  Prolonged  hot  applications  to  the  abdomen  lessen  peristalsis. 

5.  Prolonged  hot  applications  to  the  pelvis,  as  a  fomentation, 
pack,  or  sitz  bath,  relax  the  muscles  of  the  bladder,  rectum,  and 
uterus,  dilate  their  blood  vessels,  and  increase  the  menstrual  flow. 

6.  A  large  hot  application  to  the  trunk,  as  a  hot  trunk  pack  in 
biliary  or  renal  colic,  relaxes  the  muscles  of  the  bile-ducts,  gall- 
bladder, or  ureters,  and  aids  in  relieving  the  pain  due  to  spasm  of 
these  muscles. 

Hydrostatic  Effects. — Prolonged  application  of  heat  covering  a 
large  area  causes  the  peripheral  circulation  to  dilate;  if  cold  is  sub- 
stituted the  blood  vessels  will  contract  and  drive  the  blood  into  the 
internal  organs.  This  interchange  of  flow  is  termed  depletion  and 
the  means  of  producing  it  derivation  and  is  used  primarily  to  re- 
duce congestion  of  areas  and  organs.  While  reflex  effects  are  pro- 
duced through  nerve  action,  depletion  is  primarily  mechanical  and 
although  both  effects  are  produced  by  the  same  application,  one  of 
these  will,  by  its  greater  intensity,  soon  overbalance  the  other. 
There  are  definite  laws  which  govern  this  balance  which  Abbott 
defines  as  follows :  "The  first  relates  to  the  size  of  the  area  treated; 
the  second,  to  the  intensity  of  the  application ;  the  third,  to  the 
location  of  the  area." 

"1.  Size  of  Area. —  (a)  When  an  application  covers  a  small  area, 
as  an  ice-bag  or  a  jet  douche,  the  effect  is  chiefly  reflex,  and  is 
concentrated  upon  the   internal  organ  in  reflex  relation  with  the 


522  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

surface  treated.  These  applications  are  so  small  that  the  circulatory 
effect  in  driving  blood  from  the  skin  will  be  slight.  The  resulting 
hydrostatic  effect,  therefore,  being  very  slight  and  spreading  out 
over  all  the  rest  of  the  body,  will  be  of  no  importance. 

"(b)  With  all  the  large  applications  the  mechanical  or  hydro- 
static effect  soon  overbalances  and  wipes  out  the  reflex  effect.  This 
is  true  of  hot  leg-baths,  hot  packs,  full  tub  baths,  etc. 

"2.  Intensity  of  Application. — When  small  applications  are  of 
great  intensity  (very  cold  or  very  hot  or  with  strong  percussion), 
the  tendency  is  also  to  produce  a  decided  reflex  with  but  little 
mechanical  effect  upon  the  blood  current. 

"3.  Locution  of  Area. — An  application  made  over  the  heart  al- 
ways produces  a  reflex  effect,  no  hydrostatic  effect  being  perceptible. 
The  same  is  true  of  an  application  to  the  head,  the  reflex  effect 
nearly  always  being  greater  than  the  hydrostatic  effect.  On  the 
contrary,  applications  to  the  feet  or  legs  practically  always  pro- 
duce hydrostatic  effects  unless  the  applications  cover  a  very  small 
area.  This  implies  thai  certain  areas  give  reflex  effects  chiefly, 
while  with  certain  other  areas  the  mechanical  effect  predominates. " 

A->  illustrative  of  therapeutic  applications  may  be  mentioned: 

1.  The  brain.  Blood  may  be  withdrawn  from  the  brain  by  ap- 
plication of  heat  to  the  feet.  Legs,  or  the  entire  lower  limbs;  also  to 
the  spine  and  entire  surface  of  the  trunk. 

2.  Lungs.  It  is  necessary  to  use  applications  to  large  areas,  since 
the  lungs  contain  much  blood  when  congested.  These  areas  are 
the  feet  and  legs,  and  the  entire  skin  surface  of  the  trunk  and 
hips.  In  pleurisy  it  is  best  to  use  a  fomentation  directly  over  the 
affected  area. 

3.  Pelvic  organs.  Then-  are  two  principal  areas  used:  First, 
the  entire  skin  surface  of  the  hips  and  lower  abdomen,  as  by  a  hot 
sitz  bath  or  hot  hip  pack.  Second,  the  lower  limbs,  as  by  a  hoi  leg- 
bath.    P>oth  areas  may  be  treated  by  the  hot  hip  and  leg  pack. 

4.  Kidneys.  Where  there  is  much  congestion  in  the  kidneys,  it 
is  necessary  to  use  hot  applications  to  the  entire  surface  of  the 
body,  the  head,  of  course,  being  excluded.  Less  intense  congestion 
may  be  treated  by  large  fomentations  to  the  back  or  by  the  trunk- 
pack. 

.">.  'Idle  middle  ear.  The  whole  side  of  the  head  and  face  di- 
verting blood  from  the  internal  carotid  and  internal  maxillary.  If 
the  hot  compress  extends  below  the  jaw.  the  common  carotid  will 
be  dilated.  An  ice-bag  below  the  jaw  with  the  fomentation  in- 
creases the  effect    by   contracting  the   carotid. 


HYDROTHERAPY  523 

It  is  possible  and  frequently  advisable  to  combine  reflex  with  the 
derivative  action.     Thus: 

To  relieve  a  congested  uterus  apply  ice-bags  over  lower  abdomen 
which  refLexly  contracts  the  blood  vessels  of  the  uterus ;  a  hot  hip 
and  leg  pack  drawing  blood  to  the  legs.  (The  pack  covers  the 
ice-bag). 

Eenal  congestion.  Ice-bags  over  lower  sternum  with  hot  fomen- 
tations to  loins. 

Gastric  congestion.  Ice-bag  over  stomach,  hot  fomentations  to 
dorsal  region  of  back. 

Visceral  congestion.  Hot-water  bag  to  abdomen  to  divert  blood 
from  viscera  to  cutaneous  veins.  Cold  compress  to  back  which  at 
first  causes  contraction  of  the  small  vessels  then  dilatation  due  to 
reaction. 

Technic 

1.  Fomentation. — Fomentation  is  applied  preferably  by  means  of 
a  piece  of  old  blanket  about  a  foot  and  a  half  square,  which,  after 
being  saturated  with  boiling  water,  must  be  thoroughly  wrung  out 
by  means  of  a  wringer  so  that  every  possible  drop  of  water  is 
squeezed  out.  This  is  an  important  element  of  technic  for  if  any 
water  remains  we  are  liable  to  scald  the  patient.  Little  fear  of  a 
burn  need  be  entertained  if  the  part  has  been  well  rubbed  with 
an  oleate  and  all  the  hot  water  has  been  carefully  squeezed  from 
the  piece  of  blanket.  The  nurse  takes  the  hot  moist  piece  of  blanket, 
lays  it  beside  the  patient,  opens  the  blanket  covering,  then  places 
the  fomentation  upon  the  affected  part.  It  must  be  quickly  ad- 
justed to  the  part,  the  blanket  closed,  and  all  air  excluded  by  draw- 
ing the  blanket  cover  tightly  over  the  fomentation,  and  especially 
close  at  the  ends.  The  patient  will  likely  complain  of  the  intense 
heat,  but  must  be  encouraged  to  bear  it,  as  this  will  disappear 
as  soon  as  the  tissues  relax.  If  the  heat  can  not  be  endured,  the 
nurse  may  "ease"  matters  a  little  by  lifting  the  fomentation  from 
the  surface  for  a  few  seconds,  without  greatly  loosening  the  blanket 
cover,  and  again  dropping  it  in  place.  The  fomentation  may  remain 
in  place  for  five  to  ten  minutes,  and  may  be  immediately  repeated, 
or  again  as  soon  as  the  physician  deems  wise.  If  it  is  immediately 
repeated  the  parts  must  be  kept  covered  by  the  blanket  cover,  and 
the  process  gone  through  with  as  little  loss  of  time  as  possible. 
Two  pieces  of  blanket  will  be  found  useful  on  such  occasions,  the 
nurse  preparing  the  second  one  while  the  other  is  in  place  being 
thus  enabled  to  make  the  exchange  with  great  rapidity,  a  feature 


524  AFTER-TREATMEXT    OF    SURGICAL   PATIENTS 

much  to  be  desired.  The  beneficial  effect  of  the  fomentation  can 
be  decidedly  enhanced  by  terminating  the  treatment  with  a  brief 
cold  application  not  to  exceed  a  minute.  The  part  is  then  dried, 
rubbed  briefly  with  the  dry  hand  and  protected  from  the  air. 

Effect. — The  fomentation  is  used  to  relieve  pain,  produce  deri- 
vation, as  a  preparation  for  cold  treatment,  and  for  stimulating  or 
sedative  effects,  according  to  the  temperature  and  mode  of  applica- 
tion. Its  first  effect  is  that  of  a  vital  stimulant;  unless  followed  by 
a  cold  application  the  reaction  is  atonic.  A  brief  application  is 
stimulating;  prolonged  applications  are  sedative  or  depressing.  For 
sedative  effects  the  heat  should  be  moderate  and  the  application  more 
prolonged  before  renewal.  These  points  should  be  observed  in  ap- 
plying fomentations  to  the  spine  for  insomnia. 

2.  Heating  Compresses. — A  heating  compress  is  a  cold  compress 
so  covered  thai  warming  up  soon  occurs.  The  effect  is.  therefore, 
that  of  a  mild  application  of  moist  heat. 

A  heating  pack  or  compress  consists  of  an  application  to  the 
body  of  three  or  four  thicknesses  of  gauze  or  one  of  linen  or  cotton 
cloth  wrung  from  cold  Avater  and  so  perfectly  covered  with  dry 
flannel  or  mackintosh  and  flannel  as  to  prevent  the  circulation  of 
air  and  cause  an  accumulation  of  body  heat.  In  case  warming 
does  not  occur  promptly,  it  should  be  aided  by  hot-water  bottles 
or  radiant  heat.  It  is  usually  left  in  place  for  several  hours  be- 
tween other  treatments,  or  overnight.  If  left  on  overnight  it  should 
be  dry  by  morning  unless  an  impervious  covering,  such  as  a  mackin- 
tosh or  oiled  silk,  is  used.  On  removal  of  the  compress,  the  part 
should  be  rubbed  with  cold  water. 

If  the  pack  dries  out  before  being  removed,  it  will  have  a  mild 
derivative  and  sedative  effect.  If  the  coverings  prevent  drying, 
the  result  will  be  that  of  a  stronger  derivative  because  of  the  local 
sweating.  It  also  causes  relaxation  of  the  muscles  and  vasodilata- 
tion of  the  vessels  in  immediate  or  reflex  relation  with  the  surface 
treated. 

3.  Ice  Pack.-  -An  ice  pack  is  used  where  a  Large,  continuous,  and 
very  cold  application  is  desired.  Spread  cracked  ice  over  a  thick 
Turkish  towel,  folding  one  end  and  the  edges  over  this  so  as  to 
retain  the  ice.  Apply  next  to  the  skin  or  over  a  single  layer  of 
flannel.  This  may  be  used  over  the  heart,  also  over  a  consolidated 
Lung  area  in  pneumonia.  In  the  hitler  case,  it  should  never  be  ap- 
plied until  after  the  hot  packs  have  warmed  the  body  sufficiently 
to  prevent   chilling.     It  should   occasionally  be   interrupted   by  ap- 


HYDROTHERAPY  525 

plying  a  fomentation.  This  helps  to  preserve  the  desired  reflex 
effect. 

Snow  may  be  used  in  place  of  the  pounded  ice.  In  applying  an 
ice  pack  to  a  joint,  first  wrap  the  part  in  flannel  so  as  to  prevent 
actual  freezing,  then  pack  the  snow  or  pounded  ice  closely  against 
the  flannel,  forming  a  layer  about  one  inch  thick,  retaining  it  in 
place  by  a  larger  flannel  cloth  wrapped  about  all  and  pinned  to- 
gether. 

Ice  packs  should  be  interrupted  often  enough  to  prevent  freez- 
ing, and  either  the  part  rubbed  with  snow  or  a  fomentation  ap- 
plied to  renew  local  reaction. 

4.  Cold  Wet  Pack. — Requisites. — One  or  two  blankets;  a  linen  or 
cotton  sheet ;  four  small  towels  and  a  hot- water  bag. 

Technic. — The  patient  in  wrapper  sits  in  a  convenient  chair  with 
feet  in  the  bath  of  warm  water  and  with  a  cold  compress  on  the 
head.  The  attendant  then  wrings  out  the  sheet  from  the  water  in 
the  bucket  and  spreads  it  smoothly  over  the  bed,  so  as  to  reach 
near  the  foot.  The  patient  then  quickly  drops  all  clothing  and  lies 
on  the  wet  sheet  with  arms  extended.  The  attendant,  standing  on 
the  right  side,  promptly  draws  the  overhanding  left  side  of  the 
sheet  across  the  body,  smoothing  it  between  the  lower  limbs  and 
along  the  right  side.  The  arms  are  then  lowered  to  the  sides  and 
the  remaining  free  portion  of  the  sheet  is  drawn  over  the  body  and 
smoothly  adjusted  over  the  lower  limbs,  covering  in  both  arms. 
The  feet  are  left  uncovered  by  the  sheet,  but  the  hot  water  bag, 
covered  with  a  towel  is  placed  at  the  soles.  The  underlying 
blanket  is  adjusted  in  a  manner  similar  to  the  sheet,  except  that 
it  is  not  tucked  between  lower  limbs,  and  the  surplus  at  the  feet 
is  folded  under  them.  The  blanket  should  be  closely  adjusted  at 
the  neck  so  as  to  exclude  all  air.  Another  blanket,  folded  in  several 
thicknesses,  is  then  placed  over  the  entire  body  from  the  neck 
down  and  tucked  snugly  in  at  the  sides.  A  fresh  turban  of  ice- 
water  is  adjusted  to  be  changed  every  five  minutes  as  it  warms. 

It  is  found  in  many  cases  that  if  the  wet  sheet  is  allowed  to 
extend  beyond  the  feet  and  is  then  placed  over  the  feet  without 
the  use  of  the  hot-water  bag,  the  reaction  in  the  feet  is  slow  and 
correspondingly  unsatisfactory.  There  is  no  advantage  in  covering 
in  the  feet  with  the  cold  wet  sheet,  and  the  use  of  the  hot-water 
bag  favors  the  action  of  the  pack. 

5.  The  Hot  Wet  Pack. — This  is  applied  in  three  principal  ways, 
viz.,  by  means  of  a  sheet  wrung  out  of  hot  water;  by  means  of  a 
blanket  wrung  out  of  hot  water;  and  by  means  of  both.     In  many 


526  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

cast's  especially  in  treating  children,  1  lie  first  method  suffices,  and 
it  avoids  the  necessity  of  dealing  with  wet  blankets. 

Requisites. — These  arc  the  same  as  for  the  cold  wel  pack,  except 
that  a  bucket  of  hot  water  should  be  provided.  The  bed  is  pro- 
tected as  previously  described  and  on  it   two  blankets  are  spread. 

Technic:    This  is  practically  the  same  as  the  cold  wet  pack. 

6.  Hip  or  Sitz  Bath. — Requisites. — Blanket,  towels,  sitz  bath  suf- 
ficiently filled  with  water  of  the  desired  temperature  to  cover  the 
patient's  hips,  a  foot  bath  at  a  temperature  of  from  105  to  110°  F., 
except  in  the  very  hot  sitz  bath,  when  the  foot  bath  should  be  at 
least  2  or  3  degrees  warmer  than  the  sitz  bath,  a  basin  of  ice  water 
for  compresses  for  the  face  and  neck  if  for  the  hot  sitz  bath. 

Technic. — A  blanket  is  placed  about  the  patient,  being  pinned  at 
the  back  of  the  neck;  the  patient  is  seated  in  the  bath,  the  feet 
placed  in  the  foot  bath.  The  upper  edge  of  the  blanket  is  brought 
up  around  the  patient's  shoulders  and  over  the  edge  of  the  tub.  the 
lower  edge  covers  the  foot  tub. 

A  folded  towel  should  be  placed  at  the  back  and  also  at  the 
front  of  the  tub  under  the  patient's  knees  to  protect  the  patient 
from  contact  with  tin1  tub.    Avoid  pressure  on  popliteal  space. 

Cold  Sitz  Bath. — Temperature  75  to  55  F.,  the  temperature  may 
be  higher  when  the  patienl  enters  the  bath  and  rapidly  decreased 
to  the  desired  degree. 

Temperature  of  the  foot  bath,  105     to  110°  F. 

Duration. —  One  to  eighl  minutes. 

Technic-  The  patient  sits  in  the  tub  with  the  feet  in  the  foot 
tub,  the  edges  of  the  blanket  are  separated  and  placed  over  the 
patient's  shoulders;  water  is  dipped  from  the  tub  and  friction  ap- 
plied to  the  back,  patient  giving  friction  to  the  abdomen.  Friction 
is  applied  throughout  the  bath  and  may  be  given  with  the  wet  hand 
or  with  bath  mitts. 

Effects. — A  short  cold  sitz  bath  of  I  to  4  minutes'  duration,  greatly 
stimulates  the  pelvic  circulation  and  tones  up  the  musculature  of 
the  bowels,  bladder,  and  uterus.  The  lower  the  temperature,  and 
the  more  vigorous  the  friction,  the  more  intensified  are  the  effects. 

Indications. — Constipation,  subinvolution,  atony  of  the  bladder. 
Cold  sitz  baths  may  be  used  to  stimulate  the  liver  by  increasing  the 
portal  circulation.  Modified 'temperatures  may  be  used  in  treating 
children  for  nocturnal  enuresis. 

Contraindications.  Acute  inflammation  of  the  pelvic  or  abdom- 
inal viscera,  acute  pulmonary  congestion,  and  painful  affections 
of  the  bladder  and  genital  organs. 


HYDROTHERAPY  527 

Prolonged  Cold  Sitz  Bath. — Temperature. — 85  to  75°  F.  May  be 
begun  at  a  higher  temperature  and  decreased. 

Duration. — Fifteen  to  forty  minutes.  No  friction  is  applied.  If 
there  is  a  chilling  sensation,  a  fomentation  may  be  applied  to  the  spine. 

Effects. — The  pelvic  vessels  and  walls  of  the  uterus  become  ex- 
tremely contracted. 

7.  Salt  Glow. — Prepare  about  two  pounds  of  coarse  salt  and  wet 
with  cold  water.  The  treatment  should  be  given  in  a  "wet  room" 
or  in  a  bath-tub.  The  patient  stands  in  a  tub  of  hot  water.  While 
standing  at  the  side  of  the  patient  begin  with  the  arm.  Wet  the 
entire  skin  surface  of  the  shoulder,  arm,  and  hand  with  hot  water 
from  the  foot  tub.  This  is  clone  by  clipping  the  water  with  the 
hands.  Next  apply  the  wet  salt,  spreading  it  evenly  over  the  skin ; 
now  with  one  hand  on  each  side  of  the  arm,  rub  vigorously  with 
to-and-fro  movements,  until  the  skin  is  in  a  glow.  Stepping  behind 
the  patient  to  the  opposite  side,  proceed  in  the  same  manner  with 
the  other  arm. 

Retain  the  last  position  to  treat  the  front  and  back  of  the  trunk. 
With  one  hand  in  front  and  one  behind,  wet  the  skin  surface  with  hot 
water  from  the  foot  tub.  Now  spread  the  salt  as  before,  and  rub 
the  entire  skin  surface  of  the  chest,  abdomen,  shoulders,  back,  and 
buttocks.  Stepping  behind  the  patient,  with  one  hand  under  each 
arm,  continue  rubbing  with  the  salt,  treating  the  sides  of  the  chest, 
abdomen  and  hips.  Next  proceed  with  the  legs  in  like  manner. 
For  each  limb  have  the  patient  put  one  foot  on  a  low  stool  so  as 
to  bring  the  thigh  about  horizontal.  Wet  with  water  as  before  and 
rub  the  thigh,  leg,  and  foot  with  the  wet  salt.  Finish  the  treatment 
by  thoroughly  washing  off  the  salt  and  dry  the  patient. 

If  for  any  reason  the  patient  ought  not  to  stand  so  long,  he  may 
be  seated  on  a  low  stool  while  the  salt  glow  is  given. 

Proceed  as  follows :  The  patient  sits  on  a  stool  with  the  feet  in 
hot  water.  Beginning  with  the  feet  and  legs,  apply  the  water  and 
then  the  salt,  rubbing  briskly  with  short  strokes,  the  hands  being  on 
either  side  of  the  part  treated.  Next  treat  each  arm  separately; 
then  the  chest,  abdomen,  and  back  should  be  rubbed  with  the  wet 
salt,  the  attendant  standing  at  the  side  of  the  patient  with  one 
hand  rubbing  the  chest  and  the  other  rubbing  the  back.  The  pa- 
tient should  stand  while  the  buttocks  and  thighs  are  treated.  Wash 
off  the  salt  and  dry. 

The  salt  glow  is  a  vigorous  circulatory  stimulant.  Since  no  great 
amount  of  cold  water  is  applied  to  the  body,  it  does  not  require  as 
great  reactive  ability  as  the  wet  sheet  rub  or  cold  douche. 


528  AFTER-TREATMENT    OF    SURGICAL    PATIEXTS 

x.  Nauheim  Baths. — The  Nauheim  bath,  also  known  as  the  Sehott, 
carbonic  acid,  carbonic  dioxide  or  effervescing  bath,  was  originally 
administered  in  Bad-Nauheim  near  Frankfort,  Germany,  from  their 
natural  springs.  In  the  last  decade  or  so,  however,  the  hath  has 
been  prepared  artificially  in  this  country  by  adding  the  most  im- 
portant constituents  of  the  true  Nauheim  water  to  the  ordinary  full 
bath.  There  are  three  methods  in  general  usage,  which  are  employed 
in  this  country  at  the  present  time,  differing',  however,  one  from 
another  only  in  the  manner  of  producing  the  carbon  dioxide. 

The  chemicals  necessary  arc  sodium  chloride,  calcium  chloride 
hydrochloric  acid  and  sodium  bicarbonate.  The  hydrochloric  acid 
may  be  replaced  by  acid  sodium  sulphate. 

Essentials. — Full  bath  at  the  proper  temperature  (98°  to  90°  F.), 
sheet  to  cover  tub,  air  cushion,  large  turkish  sheet,  towels,  cold 
turban,  required  chemicals,  bath  thermometer. 

Technic. — The  patient  should  rest  one  hour  before  the  bath,  then 
have  his  blood  pressure,  pulse,  respiration  recorded.  "When  ready 
he  should  be  assisted  into  the  bath  in  order  to  avoid  any  unnecessary 
exertion.  Inhalation  of  the  carbon  dioxide  should  be  avoided  by 
spreading  a  sheel  over  the  tub  and  well  around  the  neck  of  the  pa- 
tient. Watch  the  patient  closely,  and  should  he  become  cyanosed, 
unduly  excited,  pulse  weak  or  irregular,  terminate  the  bath  im- 
mediately. Help  the  patient  out  of  the  tub.  and  at  once  cover  him 
with  a  warm  turkish  towelling  blanket  and  put  him  to  bed.  Chill- 
ing must  be  avoided,  if  necessary  by  aid  of  hot-water  bottles  to 
feet.  After  an  hour's  rest  again  lake  blood  pressure,  pulse,  and 
respiration.  Baths  should  not  be  given  more  often  than  five  times  a 
week,  allowing  two  days  of  rest.  In  very  weak  cases  only  every 
other  day.  On  alternate  days  it  is  a  wise  plan  to  give  the  Sehott 
heart  movements.  A  series  of  baths  usually  consists  of  18-20  or 
24  to  be  repeated  after  an  interval  of  four  to  six  months. 

Indications. — In  valvular  insufficiency  and  stenosis,  auricular  fibril- 
lation, cardiac  dilatation  and  neuroses,  Height's  disease,  chronic 
articular  rheumatism,  gout  and  obesity,  neurasthenia,  hysteria, 
rachitis,  anemia,  nephritis,  chlorosis  and  locomotor  ataxia. 

Contraindications. — Acute  inflammatory  diseases  and  in  acute  en- 
docarditis, in  extreme  arteriosclerosis,  aneurysm,  and  in  angina 
pectoris. 

Thysiologic  Effects.— The  physiologic  effects  are  stimulation  of 
the  vasomotor  apparatus  due  to  the  carbonic  acid  gas  and  the  salts 
in    solution,    principally    the    sodium    and    calcium    chloride.       The 


HYDROTHERAPY  529 

cutaneous  circulation  is  dilated,  drawing  the  blood  from  the  con- 
gested viscera,  relieving  thereby  the  labor  of  the  heart.  The 
pulse  rate  is  markedly  reduced,  but  it  becomes  stronger  and  fuller. 
The  left  ventricle  is  able  to  produce  a  more  complete  contraction. 
The  blood  pressure  at  first  rises  from  5  to  10  mm.  but  invariably 
drops  that  much  from  the  starting  point.  This  has  been  our  ex- 
perience in  almost  all  of  our  cases  complicated  by  hypertension. 
The  area  of  dullness  in  cases  of  dilatation  is  often  very  markedly 
reduced.  Stimulation  to  the  skin  increases  its  activity,  thereby 
lessening  the  labor  of  the  kidneys. 

Methods. —  (a)  Generating  the  C02  by  means  of  bicarbonate  of 
soda  and  hydrochloric  acid.  After  the  temperature  of  the  water 
has  been  properly  regulated,  the  necessary  salts,  sodium  chloride, 
calcium  chloride,  and  sodium  bicarbonate  are  added.  It  is  well 
to  strain  the  sodium  chloride  through  a  cheese  cloth  in  order  to 
remove  the  impurities  which  are  usually  present.  Next  add  a  strong 
solution  of  hydrochloric  acid  equal  in  quantity  to  the  sodium  bi- 
carbonate used,  by  pouring  it  direct^  on  the  surface  of  the  water 
from  a  small  mouthed  bottle,  distributing  it  well  over  the  entire 
surface  without  agitating  the  water.  The  layer  of  C02  which  forms 
on  the  surface,  should  be  dispersed  by  means  of  a  towel. 

(b)  The  Triton  Company  of  New  York  (Schieffelin  &  Co.)  has 
put  a  very  convenient  method  for  the  preparation  of  an  artificial 
Nauheim  bath  upon  the  market,  which  has  been  used  successfully. 

(c)  By  means  of  an  apparatus  carbonic  acid  liquid  gas  may  be 
used  instead  of  the  bicarbonate  of  soda  and  HC1.  The  principle 
is  that  of  forcing  the  gas  through  several  pieces  of  rattan  3  feet 
long  by  y2  inch  in  diameter  beveled  down  from  one  end  to  a  flat 
point.  The  gas  is  then  emitted  from  the  cut  ends  of  tubules  or 
pores  along  its  entire  length  in  the  shape  of  very  minute  globules 
which  quickly  adhere  to  and  cover  the  skin  surface  of  the  patient. 
By  means  of  a  gauge  the  amount  of  gas  can  be  absolutely  measured 
and  controlled,  thus  insuring  any  strength  of  saturation  one  may 
want.  When  this  method  is  used,  sodium  chloride,  5  pounds  to  40 
gallons  of  water  is  first  dissolved  in  the  water.  The  amount  is 
gradually  increased. 

Authorities  use  various  formulas  of  salts,  temperature  of  water 
and  duration  of  bath.  We  append  herewith  the  one  we  use  at  the 
Hydrotherapeutic  Department,  Barnes  Hospital,  but  wish  to  add 
that  we  do  not  adhere  absolutely  to  it,  changing  it  as  the  conditions 
of  the  patient  may  demand.     The  course  of  twenty  baths  extends 


530  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

over  a  period  of  four  weeks,  treatment    being  given  daily  except 
Wednesdays  and  Sundays. 


NaCl 

CaCJ 

n 

a  Bicarb 

.       11C1 

Duration 

Temp. 

Lst 

wk. 

4  lbs. 

(i  oz. 

0  oz. 

n  oz. 

5  to   7  min. 

97  to  9-j  degrees 

2nd 

" 

5    ' ' 

8    " 

8    " 

8    " 

8  to  11  " 

94  to  92 

3rd 

i  i 

i;    •• 

in    " 

In     ■• 

10    " 

12  to  13  " 

91  to  90       " 

4th 

i  c 

7    " 

12    '• 

12    " 

12    " 

14  to  15  " 

89  to  88       " 

Graduated  Tonic  Cold  Applications 

1.  Cold  Mitten  Friction. — Cold  mitten  friction  is  the  mildest 
general  treatment,  and  can  be  employed  to  advantage  even  in  the 
treatment  of  feeble,  bedridden  patients.  The  water  is  best  ap- 
plied with  a  wet  bath  mitten.  One  part  of  the  body  after  another 
should  be  rubbed,  first  with  cold  water  50°  to  75°  F.,  and  then 
with  a  rough  towel.  If  the  circulation  is  poor,  alcohol  may  be  added 
to  the  water.  The  skin  of  the  part  treated  should  become  red  and 
warm.  The  intensity  of  the  local  reaction  furnishes  a  guide  to  the 
selection  of  the  proper  tonic  measure.  If  a  good  reaction  is  ob- 
tained with  the  ablution,  stronger  measures  may  be  used,  of  which 
the  douches  have  the  greatest  range  of  usefulness. 

2.  The  Wet  Sheet,  or  Sheet  Bath. — This  important  measure  re- 
quires very  little  apparatus.  The  best  time  for  its  application  is 
late  in  the  afternoon  or  toward  night.  The  requisites  are  a  pail  or 
large  basin  of  water  at  65  P.,  a  foot  tub  with  water  at  100°  p., 
ice-water ;  two  face  towels  ;  a  bath  towel;  a  bed  with  an  extra  blanket 
at  hand,  and  protection  for  the  floor.  Put  the  sheet  into  the  water, 
letting  the  corners  hang  out.  The  patient,  dressed  only  in  one 
garment,  stands  in  the  fool  tub  containing  the  warm  water.  One 
face  towel  is  then  dipped  in  ice  water,  wrung  out,  and  wrapped 
about  the  head  like  a  turban.  The  nurse  then  places  a  pail  of 
cold  water  with  the  sheet  behind  the  patient,  and.  while  standing 
in  front  seizes  the  vet  sheet  by  two  corners  and  throws  it  around 
the  patient,  without  any  attempl  to  wring  ou1  the  sheet.  A  rough, 
smart  rapid  rub  applies  il  everywhere.  This  process  should  occupy 
about  two  minutes.  Then  drop  the  sheet  and  wrap  in  the  dry 
blanket,  and  put  the  patient  to  bed.  Lower  the  temperature  of  the 
water  1  degree  each  day  until  55    P.  be  reached. 

This  is  the  quickest  and  simplest  method  of  applying  the  drip 
sheet,  and  may  be  modified  or  extended  by  slapping  the  surface 
occasionally  with  the  hand  or  a  we1  towel,  this  increasing  the 
mechanical  irritation  of  the  skin.  In  addition,  a  basin  of  water 
10°  P.  colder  than  the  water  used  for  the  sheet  should  be  provided, 


HYDROTHERAPY 


531 


from  which  water  is  poured  over  the  head  and  shoulders  two  or 
three  times  at  short  intervals,  being  alternated  with  slapping  and 
friction  for  from  five  to  ten  minutes.  In  any  given  case  the  physi- 
cian may  judge  whether  to  commence  moderately  or  with  the  full 
technic.  The  general  effect  is  moderately  tonic,  with  the  abstraction 
of  considerable  heat. 

3.  Shallow  Bath. — Prepare  bath  at  temperature  of  75°  to  65°  F., 
four  to  six  inches  deep.  Feet  should  be  warm  before  entering  the 
bath.    The  pateint  sits  in  the  bath  and  applies  friction  to  the  chest. 


^T 


~  « 


--  '-: 


Fig.  184. — Showing  apparatus  controlling  jet  douche,  needle  douche,  shower  douche,  and 
Scotch  douche,  and  manner  of  application.  Temperature  and  pressure  of  water  under  instant 
control. 


abdomen,  arms  and  legs,  the  operator  applying  the  same  to  the 
back.  Cold  water  is  dipped  from  the  tub  and  dashed  over  the  pa- 
tient's shoulders  and  back  and  friction  continued.  The  patient  lies 
in  the  tub  giving  friction  to  the  chest  and  abdomen  while  the  opera- 
tor applies  friction  to  the  extremities. 

Duration. — Two  to  four  minutes. 

4.  Cold  Douche. — This  is  a  single  stream  of  water  under  pressure 
coming  from  a  nozzle  of  %  or  %  inch  in  diameter  at  a  distance  of 


532  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

10  to  15  feel  from  the  patient.  The  temperature  may  be  regulated 
by  valves  which  govern  the  mixing  chamber  in  the  control  table, 
and  may  be  graduated  from  a  warm  stream  down  to  the  coldest 
water  supplied.  It  is  a  powerful  stimulant  and  useful  for  its  tonic 
effect  after  the  hot-air  hath  and  circular  douche.     (Fig.  184.) 

It  is  contraindicated  in  asthma,  as  paroxysms  of  asthmatic  breath- 
ing may  he  induced.  The  sudden  contraction  of  the  pulmonary 
vessels  restricts  the  area  of  blood  subjected  to  oxidation  in  the 
lungs,  tin-  carbonic  acid  is  not  properly  eliminated,  and  a  sense 
of  suffocation  ensues.  This  is  corrected  as  reaction  occurs,  and  the 
secondary  effects  are  powerful,  tissue  change  being  highly  stimu- 
lated. Fatigue  gives  place  to  renewed  energy,  especially  if  the 
cold  applications  be  preceded  by  heat  and  followed  by  vigorous 
rubbing. 

5.  Alternating  Hot  and  Cold  Douches. — This  form  of  douche,  for 
some  unknown  reason  called  the  Scotch  douche,  produces  distinctly 
exciting  effects.  It  is  not  applicable  to  the  head  or  the  anterior 
chest,  but  may  be  applied  to  the  spine  and  posterior  thorax  and 
sides;  to  the  abdomen  and  to  the  lower  extremities.  With  tem- 
peratures alternating  between  105°  and  70°   F.,  or  possibly  a  few 

degrees   higher   and    lower,    g I   results   are    obtained;   in  robusl 

patients  the  extremes  may  reach  110 :   and  oo     F.  or  lower. 

The  Electric  Cabinet  Bath 

Compared  with  Russian  or  Turkish  baths  the  electric  lighl  cabinet 
bath  offers  many  advantages,  (a)  11  combines  both  light  and  heat. 
Lighl  is  used  because  of  its  property  of  being  able  to  penetrate 
soft  tissue  and  thus  exert  a  definite  influence  on  the  body  cells  in 
that  way.  (b)  Because  the  patient  is  more  definitely  under  the 
control  of  the  nurse,  which  is  very  important  in  advanced  cardio- 
renal  cases  where  elimination  is  so  desirable,  (c)  The  heart  action 
is  easily  controlled  by  cold  applications  to  the  head,  (d)  The  blood 
can  be  further  diverted  from  the  head  by  means  of  a  hot  foot  bath 
given  at  the  same  time,  (e)  Perspiration  can  be  Induced  in  from 
five  to  ten  minutes  with  a  temperature  of  less  than  125°.  (f)  It 
can  be  so  readily  used  for  the  purpose  of  heating  the  body  prepara- 
tory to  giving  a  hydriatic  treatment,  (g)  Can  be  installed  at  a 
relatively  small  expense  in  home  or  institution.  (Fig.  185.)  The 
stimulating  and  tonic  effects  of  radiant  Light  and  heat  upon  the 
general  metabolism  are  dm'  to  several  specific  actions  or  effects  in- 
duced on  the  tissues  in  the  circulating  fluids  of  the  body  and  are 
defined  bv  Snow  as  follows: 


HYDROTHERAPY 


coo 


"I.  The  actions  on  the  blood.  (1)  The  oxidizing  influences  of 
radiant  light  and  heat  favor  to  a  remarkable  degree  active  tissue 
metabolism.  (2)  The  oxygen-carrying  function  of  the  blood  is  en- 
riched by  an  increased  percentage  of  hemoglobin  due  to  the  direct 
action  of  light  rays,  and  (3),  the  lymphatics  are  rendered  more  ac- 
tive in  eliminating  waste  products  and  toxins  by  the  sweat  glands 
and  other  emunctories  of  the  body. 

"II.  The  superficial  end  organs  are  stimulated  to  a  greater  ac- 
tivity with  an  increased  tissue  change,  both  anabolic  and  catabolic. 

"III.  The  deep  spinal  centers  are  reflexly  stimulated  to  greater 
reflex  activity  by  the  intense  effects  of  the  applications  of  radiant 


Fig.    185. — Illustrating    electric   light   cabinet   bath. 


light  and  heat  to  the  peripheral  neurons,  thereby  arousing  greater 
general  activity  of  the  vital  centers,  particularly  the  perspiratory, 
cardiac,  and  excretory  centers. 

"IV.  The  general  diffusion  of  heat  which  takes  place  by  con- 
vection from  the  blood  heated  at  the  periphery,  promotes  general 
tissue  oxidation  and  elimination  throughout  the  organism. 

"V.  The  actinic  and  thermic  action  of  the  radiant  light  and  heat 
upon  the  germs  in  local  areas  of  infection,  causes  inhibition  of  ac- 
tivity and  destruction  of  the  germs  by  the  phagocytes  thereby  re- 


534  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

lieving  the  tissues  generally  from  the  toxic  materials  otherwise 
thrown  out. 

"VI.  The  induction  of  superficial  hyperemia,  local  or  general, 
promotes  nutrition  in  the  tissues  hy  an  increase  of  nutritious 
pabulum  distributed  through  the  tissues,  as  well  as  an  increase  in 
the  number  of  nature's  scavengers,  the  phagocytes,  where  hy- 
peremia exists,  thereby  increasing  the  general  tissue  resistance, 
as  well  as  awakening  a  greater  metabolic  activity. 

"VII.  The  stimulation  of  increased  elimination  through  the  sweat 
glands  and  other  emunctories,  induces  the  removal  from  the  system 
of  the  poisonous  toxins  which  vitiate  the  general  system  and  cause 
general    impairment     of    metabolism." 

Bibliography 

The  following  publications  were   freely  consulted   I'm    material,  as  well  as  for 
confirmation  or  otherwise  of  cur  own  experience. 
Pope:      Practical  Hydrotherapy,  Chicago  Medical   Book  Co. 
Kellogg:     Rational   Hydrotherapy,   Philadelphia,  F.  A.   Davis  Co. 
Abbott:     Hydrotherapy,  Loma   Linda,  Cal.,  College   Press. 

Barush:     Hydrotherapy,  New  York,  Win.  W I  &  Co. 

Hinsdale:     Hydrotherapy,  Philadelphia,  W.  B.  Saunders  Co. 

Sehott:     Treatments  of  Chronic  Diseases  of  the   Heart.   Philadelphia,   P.    Blakis 

ton  's  Son  &  Co. 
Snow:     Radiant    Light    and    Heat    and    Convective    Heat,    Xeu     York,    Scientific 

Author  Hub.  Co. 


CHAPTER  LIII 

POSTOPERATIVE  TREATMENT  BY  RADIUM  AND  THE 
ROENTGEN  RAYS  IN  MALIGNANCY 

By  Russell  H.  Boggs,  Pittsburgh,  Pa. 

Discussion  of  the  value  of  radium  and  the  roentgen  rays  in 
malignancy  necessitates  dealing  with  the  various  types  and  stages, 
and  the  citation  of  results  produced  by  each  agent  alone,  as  well 
as  when  used  as  a  supplementary  treatment  to  surgery.  In  cer- 
tain locations  and  stages  of  malignancy,  anteoperative  or  preliminary 
treatment  is  undoubtedly  advisable.  In  advanced  growths  in  the 
mouth  or  throat,  and  in  advanced  carcinoma  elsewhere,  the  results 
obtained  both  by  radium  and  the  roentgen  rays,  have  given  them  a 
place  as  a  routine  method  alone ;  for  instance,  in  the  treatment  of  se- 
lected cases  of  epithelioma.  Postoperative  treatment  by  these  agents, 
therefore,  can  not  be  satisfactorily  discussed  without  considering, 
separately,  their  positive  values  when  used  apart  from  surgery,  and 
citation  of  cures  by  the  rays  alone  will  only  emphasize  their  value 
in  treatment  of  postoperative  cases. 

Before  any  one  can  use  radium  and  the  roentgen  rays  intelligently, 
it  is  not  only  necessary  to  study  the  properties  of  radioactive  sub- 
stances, but  also  their  physiologic  actions  on  both  normal  and  dis- 
eased tissues.  Interest  from  the  beginning  centered  around  the 
action  which  the  rays  had  upon  malignant  cells,  and  as  a  result  of 
detailed  studies  by  many  investigators,  the  treatment  of  malignancy 
by  radiotherapy  has  been  placed  upon  a  rational  basis. 

Investigators  have  shown  that  the  rays  given  off  both  by  the 
radium  and  x-ray  tube  act  primarily  on  the  nuclei  of  the  cells  and 
inhibit  their  power  of  proliferation  before  the  function  of  the  cell 
is  impaired.  Embryonic  cells  and  those  which  are  undergoing  ac- 
tive proliferation  are  the  most  susceptible.  It  has  been  shown  that 
malignant  growths  are  retarded  by  radiation  and  become  less  malig- 
nant, although  they  may  not  have  diminished  in  size  or  disappeared. 
By  further  increasing  the  quantity  of  radiation,  the  injury  becomes 
more  pronounced,  and  the  cells  are  completely  destroyed,  the  rays 
acting  differently  on  the  various  types  of  cells,  destroying  one  kind 
of  tissue  and  leaving  the  other  adjacent  tissues  intact  or  so  slightly 
injured  that  they  will  completely  recover. 

535 


536  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

The  therapeutic  action  of  the  rays  on  a  new  growth  consists,  not 
only  in  the  destruction  of  the  tumor  cells,  but  also  in  the  change 
produced  in  the  blood  vessels.  The  endothelial  cells  of  the  intima 
degenerate,  the  lumen  of  the  vessels  retract,  finally  being  obliterated, 
and  consequently  the  tumor  cells  can  not  obtain  the  nourishment 
needed  for  their  maintenance  of  life  and  for  their  proliferation. 

It  may  be  of  interest  to  call  attention  to  some  of  the  reasons  bet- 
ter results  were  not  obtained  in  the  early  days  of  radiotherapy, 
even  by  those  who  were  good  clinicians  and  pathologists.  Eadia- 
tions  from  radium  are  of  a  complex  character  as  regards  penetra- 
tion, and  it  is  necessary  for  some  of  the  rays  to  be  absorbed  before 
reaction  takes  place.  Kays  of  low  penetrability  are  the  most  active 
physiologically.  Often  rays  of  too  low  or  too  high  penetration  were 
employed;  if  too  low,  only  the  surface  of  the  lesion  is  treated  while 
if  too  high,  energy  is  wasted  and  the  best  form  of  radiation  is  de- 
feated. Rays  given  off  radium  are  known  as  alpha,  beta,  and 
gamma.  Many  did  not  know,  in  the  early  days,  whether  the  gamma 
or  beta  ray  predominated. 

The  therapeutic  value  of  radium  can  not  be  thoroughly  under- 
stood if  it  has  not  been  studied  with  a  sufficiently  complete  and 
varied  range  of  filtration.  11  is  also  necessary  to  know  how  to  cut 
off  the  low  rays,  which  are  not  wanted  for  the  lesions  under  treat- 
ment, and  to  know  the  method  of  avoiding  the  deleterious  effects 
of  these  rays,  as  well  as  to  understand  the  secondary  radiations 
set  up  by  the  various  filters  employed.  In  the  beginning  no  one 
was  familiar  with  filtration  and  secondary  radiation.  They  did  not 
know  whether  they  were  treating  the  patient  with  beta  or  gamma 
rays.  Good  results  were  accomplished  only  after  this  was  known  as 
well  as  the  limitations  of  radium.  Radium,  I  believe,  when  properly 
applied,  is  the  most  efficient  form  of  radiation  we  have,  today,  for 
a  depth  of  from  two  to  three  centimeters,  but  large  areas  can  not 
be  treated  with  it.  and  when  it  is  necessary  to  ray  the  adjacent 
glands  it  should  be  supplemented  by  the  roentgen  rays.  Modern 
radiation  means  the  use  of  radium  and  the  roentgen  rays  with  the 
improved  technic,  using  the  Coolidge  x-ray  tube. 

The  treatment  of  malignancy  demands  specialized  study.  Every 
physician  or  surgeon  who  treats  malignancy  should  know  its  various 
forms  and  stages,  and  also  know  what  has  been  accomplished  by 
radium,  roentgen  rays,  surgery  and  any  other  method  by  which 
results  have  been  obtained. 

Carcinoma  of  the  Breast. — Treatment  of  carcinoma  of  the  breast 
by  roentgen  rays  has  been  carried  out  by  many  during  the  past  15 


RADIUM    AND   ROENTGEN   RAYS   IN    MALIGNANCY  537 

or  16  years,  and  is  today  a  recognized  method  in  the  treatment  of 
postoperative  cases,  recurrent  and  metastatic,  primary  inoperable 
and  primary  cases  which  do  not  permit  operation.  For  a  long  time 
it  was  taught  and  accepted  as  indisputable  that  the  only  proper 
and  scientific  method  was  the  radical  operation,  which  meant  the 
surgical  extirpation  of  the  growth  even  in  the  hopeless  stages ;  but 
today  it  must  be  recognized  that  surgery,  taught  so  long  as  the  only 
method,  is  really  only  part  of  the  treatment.  Though  operation 
still  holds  first  place  in  the  early  cases,  even  at  this  stage  it  should 
be  supplemented  by  roentgen  therapy.  This  sentiment  is  spreading 
among  some  of  the  leading  surgeons,  who  in  the  past  did  the  most 
radical  operations  for  cancer  of  the  breast  at  any  stage,  their  ad- 
vanced views  springing  mainly  from  comprehensive  experience  with 
a  great  number  of  cases  traced  carefully  to  their  end  results.  Roent- 
gen therapy  is  taking  the  place  of  the  ultra-radical  operation,  such 
as  removal  of  the  supraclavicular  glands,  or  the  clavicle. 

It  is  our  duty  as  roentgenologists  to  teach  the  profession  the  in- 
dications for  roentgen  therapy  and  that  postoperative  treatment 
is  just  as  important  as  asepsis  before  and  during  the  operation. 
While  statistics  are  of  little  value,  it  can  be  safely  stated  that  proper 
postroentgen  treatment  will  prevent  from  25  to  50  per  cent  of  re- 
currences even  in  the  early  cases,  because  cancer  cells  can  be  de- 
stroyed at  a  greater  depth  and  distance  from  the  original  growth. 
If  the  surgeons  can  cure  40  per  cent  of  cases  in  a  certain  class, 
why  not  make  it  90  per  cent  or  more?  It  will  be  a  big  task  to 
demonstrate  this  fact  to  surgeons,  inasmuch  as  many  of  their  cases 
will  receive  inefficient  therapy  in  the  hospital  by  a  nonmedical  tech- 
nician, and  if  results  are  not  obtained,  they  will  relieve  themselves 
of  the  responsibility  by  saying  the  rays  were  at  fault.  Then,  too, 
it  is  feared  that  too  much  therapeutic  work  is  undertaken  in  a  half- 
hearted manner,  even  by  many  who  can  do  exceptionally  good  roent- 
genograph^ work.  Surgeons  long  ago  agreed  that  too  many  un- 
qualified physicians  operate.  Since  they  know  that  proficiency  is 
necessary  in  operation,  they  should  realize  that  just  as  much  care 
and  skill  is  required  in  giving  therapy. 

Treatment  of  carcinoma  of  the  breast  by  roentgen  rays  has,  com- 
paratively speaking,  passed  through  the  same  stages  as  surgery. 
The  early  stage  might  be  compared  with  surgical  treatment  of  a 
quarter  of  a  century  ago  when  they  only  amputated  the  breast. 
Our  technic  in  the  beginning  was  very  crude ;  we  neither  used  filters 
nor  had  a  standard  dose,  and  we  omitted  important  chains  of 
lymphatics  where    metastases   frequently   occurred.      Indeed,    it   is 


538  AFTER-TREATMENT    OP"    SURGICAL    PATIENTS 

quite  remarkable  that  a  creditable  number  of  good  results  were 
obtained  when  one  considers  the  inefficient  equipment  and  faulty 
teehnic  employed. 

Today  many  have  standardized  their  dosage  and  with  the 
Coolidge  tube,  arc  able  to  give  uniform  treatment,  but  the  amount 
of  radiation  which  should  be  given  has  not  been  determined  in  a 
uniform  manner  by  the  roentgenologists.  This  is,  of  course,  a  diffi- 
cult task,  each  case  being  an  individual  study;  nevertheless,  it  is 
time  more  attention  be  given  to  the  postoperative  treatment  of  car- 
cinoma of  the  breast,  in  order  to  standardize,  as  far  as  possible, 
a  teehnic  for  the  different  types  and  stages  of  the  disease,  just 
as  surgeons  have  standardized  operation. 

Take  a  given  case;  let  us  decide  what  amount  of  radiation  should 
be  given  immediately  after  the  operation,  how  extensive  it  should 
be.  when  and  how  often  it  should  be  repeated.  All  roentgenologists 
agree  that  each  case  should  have  a  full  physiologic  dose,  or  all  that 
the  skin  Avill  stand,  not  only  to  the  anterior  chest  Avail,  but  to  every 
chain  of  lymphatics  draining  the  breast,  as  well  as  to  the  opposite 
side  of  the  body.  The  location  and  stage  of  the  tumor;  the  kind 
of  operation  performed,  and  the  physica]  condition  of  the  patient 
must  be  considered  carefully  in  determining  treatment.  The  writer 
believes  two  to  three  times  the  usual  dose  of  radiation  can  be 
safely  given  in  the  supraclavicular  region,  in  places  where  there  is 
no  sear  and  where  the  cutaneous  circulation  has  not  been  interfered 
with  by  the  operation.  A  study  of  the  supply  of  the  lymphatics  and  the 
manner  in  which  they  metastasize  should  be  made  by  every  one 
treating  carcinoma  of  the  breast.  This  will  never  be  done  by  the 
nonmedical  technician.  In  fact,  too  little  attention  everywhere  has 
been  given  to  the  supply  of  the  lymphatics,  their  depth  and  extent, 
and  the  besl  manner  of  thoroughly  radiating  each  chain.  Raying 
the  lymphatics  sufficiently  to  proper  depth  and  coextensive  with 
metastases  is  indeed  no  easy  task.  It  requires  as  much  care  and 
judgmenl  as  the  most  careful  dissection.  Efficienl  radiation  makes 
operation  more  radical,  increases  the  percentage  of  cures  in  early 
as  well  as  in  more  advanced  cases,  and  delays  recurrence  in  all 
cases. 

A  visii  to  our  besl  hospitals  shows  that  a  very  small  percentage 
of  carcinomas  operated  upon  receive  proper  roentgen  treatment. 
Who  is  at  fault  .'  Both  the  surgeons  and  the  roentgenologists.  Many 
surgeons  refer  for  postradiation  only  cases  which  are  really  con- 
sidered inoperable  and  then  often  qoI  until  a  recurrence  has  taken 
place.     Still   they   would    like  to  make  the  operation  more  radical. 


RADIUM    AND   ROENTGEN   RAYS    IN    MALIGNANCY  539 

Do  they  not  know  that  this  can  be  accomplished  by  the  roentgen 
rays?  Many  cases  have  been  treated  as  a  placebo,  rather  than  a 
real  effort  to  effect  a  cure.  Often  these  patients  would  be  given 
a  few  treatments  within  a  week  or  ten  clays  after  the  operation  with 
no  further  radiation.  This  was  called  postradiation,  and  from  this 
slipshod  method  the  physicians  and  surgeons  drew  their  conclu- 
sions as  to  the  value  of  the  roentgen  rays.  Had  they  taken  no  more 
pains  with  the  operation,  surgery  would  long  ago  have  been  aban- 
doned. 

If  we  as  roentgenologists  are  going  to  treat  cancer  of  the  breast, 
we  must  be  familiar  with  the  different  forms  and  stages,  so  that  our 
opinion  will  be  worth  something  in  deciding  the  best  method  or 
methods  of  treatment.  We  should  know  whether  or  not  operation 
is  indicated,  as  well  as  what  can  be  accomplished  with  the  roentgen 
rays.  We  must  be  consultants,  rather  than  merely  technicians  as 
some  have  been  in  the  past. 

It  has  been  pointed  out  by  competent  surgeons,  when  an  opera- 
tion was  performed  before  a  diagnosis  could  be  made  clinically 
without  a  microscope,  that  80  per  cent  of  the  cases  could  be  cured. 
Deaver  and  McFarland  in  their  recent  book,  ''The  Breast,  Its 
Anomalies,  Its  Diseases,  and  Their  Treatment,"  make  the  following 
statement: 

"'It  has  been  stated  that  80  per  cent  of  patients  in  whom  the 
disease  is  confined  to  the  breast,  as  proved  by  both  macroscopic  and 
microscopic  examinations  of  the  tissues  adjacent  to  this  organ  are 
permanently  cured  of  their  disease  by  the  radical  operation.  There- 
fore, a  patient  presenting  a  small  movable  mass  localized  to  the 
breast,  can  be  assured  that  four  out  of  five  cases  of  a  similar  nature 
are  cured  by  operation.  When  axillary  lymph  nodes  are  palpably 
enlarged  as  the  result  of  metastases,  the  chances  of  operative  cure 
are  at  once  diminished  to  one  in  five."  The  authors  further  say  that, 
"in  the  opinion  of  many  surgeons,  involvement  of  the  supracla- 
vicular glands  is  a  contraindication  against  operation." 

The  absence  of  palpable  enlargement  does  not  always  mean  an 
absence  of  carcinomatous  involvement.  Halsted  found  that,  not- 
withstanding the  present  clay  extensive  operation,  death  from  me- 
tastases occurs  in  23.4  per  cent  cases,  and  even  in  cases  with  mi- 
croscopically negative  axilla.  A  few  years  ago  scarcely  any  of  the 
physicians  or  surgeons  realized  the  importance  of  this ;  and  even 
today  there  are  some  who  are  operating  on  late  or  advanced  cases, 
expecting  the  same  results  that  the  leading  authorities  obtained  in 
early  cases.     Retraction  of  the  nipple,  axillary  and  supraclavicular 


540  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

involvement  are  late  symptoms  from  a  prognostic  standpoint.  Phy- 
sicians who  talk  about  favorable  eases  for  operation  when  the  nipple 
is  retracted,  as  "well  as  when  the  axillary  and  supraclavicular  in- 
volvement is  present,  should  read  Deaver's  book  quoted  above;  in 
fact,  any  one  treating  cancer  of  the  breast,  who  reads  this  book 
carefully,  would  not  be  so  radical  from  a  surgical  standpoint,  and 
would  appreciate  more  the  value  of  the  roentgen  rays. 

Deaver  questions  whether  as  much  palliation  is  received  from  op- 
erative as  from  nonoperative  methods,  and  expresses  his  general 
dissatisfaction  with  operations  of  a  palliative  nature  in  the  treat- 
ment of  carcinoma  of  the  breast:  since,  in  certain  cases  the  disease 
has  been  excited  to  greater  activity  by  an  incomplete  operation, 
and  the  life  of  the  patient  considerably  shortened.  In  this  connec- 
tion he  mentions  the  unreserved  statement  of  Bloodgood.  that  "in- 
complete operation  hastens  death."  He  further  states  that  since 
lv!'7  such  extraordinary  advances  have  been  made  in  roentgen- 
therapy  that  remove  most  of  the  indications  for  the  ultraradical 
operative  procedures,  which  have  practically  no  curative  value,  and 
a  primary  mortality  of  at  least  25  per  cent.  Since  Deaver's  care- 
fully prepared  volume  is  a  resume  of  the  entire  medical  literature 
and  of  world-wide  clinics,  and  since  he  has  included  a  valuable 
chapter  of  roentgentherapy  of  Pfahler's,  it  deserves  more  than  pass- 
ing notice. 

For  my  part,  I  am  well  convinced,  from  the  cases  I  have  seen 
during  the  past  fifteen  or  sixteen  years,  that  an  incomplete  opera- 
tion should  never  be  performed,  not  even  for  palliation.  It  is  just 
as  accessary  that  as  complete  a  study  of  lymphatics  of  the  breast, 
Ihe  frequency  and  extent  of  their  metastases  should  be  made  by 
the  roentgenologisl  as  by  the  surgeon.  The  lymphatic  supply  of  the 
breast  is  greater  than  that  of  almost  any  organ  of  the  body,  so 
that  metastases  even  of  the  abdominal  organs  occur  more  frequently 
than  is  generally  realized.  In  the  past  many  have  given  a  few 
treatments  over  the  line  of  incision,  axilla  and  supraclavicular  areas. 
Such  treatment  is  very  incomplete,  since  it  omits  those  lymphatics 
which  frequently  metastasize;  namely,  suprascapular,  anterior  pec- 
toral of  the  opposite  side,  internal  mammary,  subscapular,  para- 
vertebral, xiphoid  and  inguinal  group.  A  study  of  bone  metastases 
makes  us  realize  how  extensively  the  lymphatics  become  involved. 
It  is  known  that  metastases  may  occur  in  distant  glands  at  a  very 
early  stage  of  the  disease.  While  the  axillary  glands  are  the  most 
frequently  involved  (indeed  so  frequently  involved  that  the  mi- 
croscopic freedom  at  the  time  of  operation   is  the  exceptional)    in 


RADIUM    AND   ROENTGEN    RAYS   IN    MALIGNANCY  541 

some  cases  they  are  free  when  there  is  involvement  of  the  ab- 
dominal or  other  internal  viscera.  The  value  of  palpable  glands 
is  overestimated.  The  lymphatics  in  the  axilla  may  become  en- 
larged by  previous  infections  of  the  arm  or  breast.  Therefore,  it 
requires  judgment,  and  in  some  cases  microscopic  examinations,  be- 
fore the  cause  of  enlargement  can  be  positively  determined.  Me- 
tastasis, too,  varies  with  the  different  types  of  tumor  and  occurs 
earlier  in  the  young  and  fat  patients,  owing  to  the  greater  richness 
of  the  lymphatic  supply.  Efficient  roentgen  treatment  must  take 
care  of  these  variations. 

It  is  generally  conceded  that  the  smaller  the  caliber  of  the 
lymphatics,  as  well  as  the  greater  the  degree  of  senile  atrophy,  the 
greater  the  tendency  to  oppose  cancer  dissemination.  If  the  roent- 
gen rays  did  nothing  more  to  adjacent  lymphatics  than  produce  a 
sclerosis,  the  treatment  would  still  be  indicated  for  retarding  the 
disease.  The  frequent  involvement  of  one  breast  to  the  other,  is 
due  to  the  distribution  of  the  lymphatics  of  the  chest  wall.  Autopsy 
has  shown  that  the  liver  metastasizes  more  frequently  than  any  of 
the  internal  organs  and  in  many  cases  becomes  involved  in  com- 
paratively early  stages. 

According  to  Handley,  the  frequent  involvement  of  the  liver  is 
attributed  to  the  cancerous  dissemination  along  the  deep  lymphatics 
of  the  fascia  of  the  thoracic  wall  to  the  epigastrium  and  to  the 
umbilicus,  whence  these  cells  follow  the  subserous  lymphatics  to 
become  deposited  either  on  the  surface  of  the  liver,  or,  are  conveyed 
along  the  lymphatics  of  the  falciform  ligament  to  the  portal  glands. 
If  Handley 's  deductions  are  correct,  we  should  never  omit  heavy 
treatment  over  the  epigastric  region.  The  next  in  frequency  are 
the  lungs  and  pleura,  which  are  supposed  to  become  involved  through 
the  intercostal  or  supraclavicular  lymphatics.  A  study  of  autopsies 
shows  that  almost  any  organ  of  the  body  may  metastasize  from 
cancer  of  the  breast,  and  however  much  confined  to  the  superficial 
tissues  this  dissemination  may  seem  to  be,  no  one  can  absolutely 
foretell  how  far  the  so-called  "microscopic  growing  edge"  of  cancer 
may  extend.  Bone  metastasis  increases  with  the  proximity  of  the 
primary  growth,  the  clavicle  and  distal  extremities  rarely  being 
involved. 

Many  consider  a  three-year  limit  a  cure  of  cancer  of  the  breast, 
but  we  can  not  be  sure  recurrence  will  not  take  place  later.  Barker 
has  stated  that  30  per  cent  of  the  cases  that  are  clinically  cured  at 
the  end  of  three  years  later  die  of  cancer  of  the  breast.  Since 
operation  has  about  reached  its  limit  and  since  ultraradical  opera- 


542  AFTER-TREATMENT    OP    SURGICAL   PATIENTS 

lions  are  not  practical  until  some  better  form  of  treatment  is  dis- 
covered, the  splendid  results  achieved  from  radiation  furnish  more 
than  sni'iieieiil  reasons  for  giving  every  ease  id'  carcinoma  of  the 
breast  postroentgen  treatment.  This  should  be  done  even  if  the 
tumor  is  only  as  large  as  a  filbert,  because  even  in  such  cases,  there 
may  be  early  and  fatal  metastases.  Handley  says  the  pelvic  viscera 
are  involved  in  8.6  per  cent  of  Hie  early  cases  in  young  patients, 
and  in  only  4.8  per  cent  of  the  late  i-iim's  of  older  patients. 

While  roentgen  rays  find  their  most  useful  field  in  postoperative 
therapy,  it  is  difficult  to  convince  either  the  patient  or  the  average 
physician  or  surgeon  of  this  fact,  because  they  can  not  see  that  any- 
thing has  been  accomplished.  It  is  the  teachers  of  surgery  first  of 
all  whom  we  mint  convince,  because  today  they  have  come  to  realize 
that  the  most  radical  operation,  even  in  the  early  cases,  does  not 
always  reach  the  cancel'  growing  edge. 

Man\-  roentgenologists  have  adopted  Hie  following,  or  its  equiva- 
lent, as  a  standard  dose,  or  the  amount  which  cadi  area  id'  the  skin 
will  tolerate  safely  using  a  Coolidge  tube  and  a  modern  transformer, 
tube  distance  s  inches,  filtering  the  rays  with  4  millimeters  of 
aluminum,  with  a  f)  inch  parallel  spark  gap,  25  milliampere  minutes 
are  given.  With  mosl  transformers  this  dose  will  measure  20X 
Koenig-Gauss  modified  Kienbock  scale.  Mosl  of  us  would  like  to 
give  more  radical  Ireatment  in  order  to  produce  better  end  results, 
and  every  one  has  been  looking  for  some  means  by  which  the  skin 
will  tolerate  larger  doses  safely.  I  give  larger  doses  than  this  over 
the  supraclavicular  area  as  soon  as  possible,  because  this  is  a  place 
often  involved,  and  the  surgeon  seldom  advises  opening  this  chain. 
because  when   involved,  many  have   learned   it    is  really   inoperable. 

1'nless  the  roentgenologist  has  witnessed  the  operation,  he  should 
always  obtain  a  careful  report  from  the  surgeon  as  to  the  location 
of  the  growth  in  the  breast,  as  well  as  the  extent  of  the  disease  and 
type  of  tumor.  Then  the  amount  of  treatment,  as  well  as  the  most 
important  regions  to  treat  can  be  determined.  We  all  know  that 
not  only  the  axilla  and  opposite  side,  but  also  the  glands  in  the 
pelvis,  should  receive  postradiation  if  the  best  results  are  to  be 
obtained,  but  this  is  not  always  practical;  first,  because  the  patients 
will  not  consent  to  such  a  lengthy  course  of  treatment,  and 
secondly,  because  the  number  of  square  inches  that  can  be  radiated 
is  limited  when  a  full  dose  is  given  more  than  once.  Xone  are  able 
to  tell  in  the  individual  cases  what  chain  or  chains  of  lymphatics 
have  metastasized.  If  the  growth  is  small  and  situated  to  the  inner 
edge  of  the  breast,  it  would  probably  be  more  important   to  ray  the 


RADIUM    AND   ROENTGEN    RAYS   IN    MALIGNANCY  543 

opposite  breast,  opposite  axillary,  supraclavicular  and  suprascapu- 
lar areas,  than  the  axilla  of  the  affected  side,  on  account  of  the  loca- 
tion of  the  lymphatics  which  drain  the  sternal  side  of  the  breast. 
The  inner  side  is  rarely  involved  as  compared  with  the  axillary.  All 
ray  both  the  axilla,  supraclavicular  and  suprascapular  areas,  as 
well  as  the  anterior  chest  wall  and  many  ray  the  opposite  side,  but 
as  before  stated,  since  the  viscera,  particularly  the  liver,  medias- 
tinum, lungs  and  pleura  so  frequently  metastasize,  treatment  should 
be  directed  to  these  organs  as  well.  This  is  the  least  that  should 
receive  postroentgen  therapy,  and  is  never  wide  or  extensive  enough 
in  advanced  or  recurrent  cases.  An  examination  at  autopsy  of 
the  lymphatics  which  metastasize  will  convince  one  of  this  fact. 
What  we  are  looking  for,  therefore,  is  the  best  method  of  raying 
the  widest  area  with  the  least  effect  on  the  skin,  and  the  least  loss 
of  radiant  energy.  I  have  adopted  the  following  method,  and  the 
experience  gained  from  treatment  of  recurrences  has  made  me  in- 
crease the  areas  from  time  to  time  : 

1.  In  order  to  prevent  recurrence  in  the  wound,  and  destroy  any 
foci  in  lymphatics  of  the  anterior  chest  wall  leading  up  to  the  inner 
clavicular  area,  three  to  four  areas  of  anterior  chest  wall  receive 
treatment,  the  last  being  directed  downwards  towards  the  liver. 
Then  the  liver  area  is  given  one  anteriorly,  one  laterally  and  one 
posteriorly.  With  this  amount  of  treatment,  the  scar  is  nearly  all 
removed  and  a  recurrence  in  the  area  is  rare  in  comparison  with 
the  number  of  recurrences  in  cases  not  treated  by  radiation. 

2.  The  axilla  receives  from  three  to  four  doses  and  is  cross-tired 
as  much  as  possible.  One  area  below  the  axilla  can  be  covered  by 
one  treatment  laterally.  The  supraclavicular  glands  are  usually 
involved  from  the  axillary. 

3'.  The  supraclavicular  region  is  divided  into  four  areas :  one 
directed  obliquely  inwards  including  the  lower  cervical  glands,  one 
downward  through  the  shoulder  area  towards  the  axilla,  one  ob- 
liquely downward  and  backward  through  the  clavicle,  and  one  ob- 
liquely forward  from  the  posterior  surface. 

4.  The  suprascapular  area  much  more  frequently  metastasizes 
than  the  subscapular.  Each  should  receive  a  full  dose  on  the  af- 
fected side,  while  on  the  opposite  side  the  subscapular  area  might  be 
omitted  in  early  cases. 

5.  The  mediastinum  should  receive  one  or  two  treatments  from  the 
posterior  to  an  area  between  the  spine  and  scapula  of  the  opposite 
side  directed  towards  the  affected  breast  region. 


544  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

6.  The  opposite  side  is  rayed  according  to  indications  and  never 
receives  less  than  from  4  to  8  treatments  during  the  course. 

7.  The  epigastric  region  must  never  be  omitted,  as  this  is  one  of 
the  avenues  by  which  the  liver  and  pelvic  viscera  metastasize. 

The  interval  between  the  first  and  second  course  of  treatments  is 
four  weeks.  However,  in  most  cases  the  supraclavicular  glands  are 
rayed  again  in  two  weeks  instead  of  four. 

In  treating  the  areas  mentioned  the  rays  must  be  so  directed  that 
the  deep  glands  in  the  axilla,  under  the  clavicle  in  the  me- 
diastinum, those  leading  to  the  liver,  and  all  the  viscera  which 
metastasize,  will  receive  a  full  roentgen  dose.  This  means  that 
cross-firing  must  be  employed,  so  that  the  deep  glands  will  be  given 
from  3  to  7  times  the  amount  that  is  given  to  any  skin  area.  If  we 
give  20X  Koenig-Gauss  modified  Kienbock  scale  dose,  at  the  surface, 
in  order  that  the  tissues  at  a  depth  of  2  inches  receive  20X,  suffi- 
cient ports  of  entry  must  be  employed  to  make  up  for  the  amount 
of  intensity  of  the  lighl  which  is  lost  by  distance  and  by  absorption 
by  the  tissues.  If  the  glands  to  be  rayed  are  four  inches  from  the 
skin,  more  cross-firing  or  more  ports  of  entry  must  be  used  than 
if  the  glands  are  only  two  inches  Prom  the  skin.  Experiments  have 
shown,  if  the  glands  to  be  treated  are  below  the  surface,  that  the 
intensity  diminishes  from  100  to  15;  that  is.  about  one  seventh  of 
that  at  the  surface.  I  am  certain  that  the  majority  of  those  treating 
carcinoma  of  the  breasl  by  the  roentgen  rays  employ  too  few  ports 
of  entry  and.  consequently,  the  deep  tissues  receive  only  a  frac- 
tional dose.  This  failure  to  employ  deep  therapy  is  responsible 
for  many  recurrences. 

For  the  past  five  or  six  years,  I  have  considered  anteoperative 
roentgen  therapy  a  very  important  and  useful  field  in  early,  as  well 
as  in  advanced,  carcinoma  of  the  breast,  but  only  comparatively 
few  cases  have  been  referred,  as  surgeons  do  not  want  the  opera- 
tion to  be  delayed  for  three  or  four  weeks.  Tt  is  a  demonstrated 
fact  that  in  lymphatics  where  the  vessels  are  of  a  small  size,  car- 
cinomatous cells  do  not  disseminate  nearly  so  readily  as  where 
they  are  of  a  larger  size.  It  lias  been  proved  thai  after  roentgen 
therapy,  the  lymphatics  undergo  a  sclerosis,  thus  reducing  the 
size  of  both  the  lymph  nodes  and  vessels,  which  in  turn  reduces 
the  danger  of  metastases.  A  cancerous  mass  after  being  rayed 
changes  in  type,  becoming  more  scirrhous  and  is  rendered  much 
less  malignant.  Carcinomatous  tumors  in  the  breasl  which  have 
been  growing  very  rapidly  will  be  checked  and  reduced  in  size 
within    a    very   short    time   after    full   doses    of    radiation.     It    has 


RADIUM    AND    ROENTGEN    RAYS    IN    MALIGNANCY  545 

been  suggested  that  some  of  the  patients  are  rendered  "immune" 
to  the  growth  of  carcinoma  for  some  time  after  such  treatment. 
However,  no  one  can  prove  at  present  whether  there  is  really  any 
immunity,  or  whether  the  checking  of  the  growth  and  improvement 
in  the  general  health  of  the  patient  are  due  entirely  to  histologic 
changes  in  the  tissues.  Observers  agree  that  the  type  of  tumor 
changes  and  that  the  danger  of  metastases  is  reduced  by  such  treat- 
ment. 

Anteoperative  treatment  will  often  render  a  more  advanced  case 
inoperable,  and,  if  deep  metastases  have  not  already  taken  place, 
more  permanent  cures  can  be  obtained  surgically.  As  I  have  before 
mentioned,  metastases  will  not  occur  so  readily  if  the  caliber  of 
the  Emphatic  vessels  has  been  reduced  by  treatment.  However, 
if  the  liver  or  any  other  of  the  internal  viscera  have  metastasized 
before  the  treatment  is  given,  the  cure  by  operation  would  be  only 
an  apparent  cure.  But  the  operation  would  not  hasten  metastases 
as  it  would  without  anteoperative  treatment.  Postoperative  roent- 
gen treatment  can  not  take  the  place  of  anteoperative  treatment 
as  many  think.  I  have  a  few  cases  apparently  well  after  three  to 
five  years,  which  verifies  this  fact. 

We  all  know  much  palliation,  and  many  times  a  temporary  cure, 
can  be  produced  in  inoperable  and  recurrent  cases.  A  study  of  the 
lymphatic  supply  of  the  breast  and  the  extensive  metastases,  usually 
visceral,  which  have  already  taken  place,  explains  why  the  results 
are  often  only  temporary,  or  from  one  to  three  or  more  years. 

Carcinoma  of  the  Uterus. — The  value  of  radium  is  being  recog- 
nized at  present  by  most  of  the  gynecologists  in  the  treatment  of 
carcinoma  of  the  cervix,  at  least  in  certain  stages.  Since  the 
pathologist,  surgeons,  and  radiotherapeutists  are  working  together 
and  making  a  careful  study  of  not  only  the  local  growth  but  the 
metastases  as  well,  more  rapid  progress  will  be  made.  Radium  is 
being  employed  today  in  hopeless,  inoperable,  borderline,  and  in 
early,  as  well  as  in  postoperative  cases. 

The  local  effects  of  radium  in  hopeless  carcinoma  are  very  strik- 
ing; the  bleeding  diminishes  and  disappears,  and  the  offensive  dis- 
charge is  checked  and  becomes  odorless.  The  local  condition  changes 
in  character;  usually  within  two  to  four  weeks  after  the  first 
treatment  has  been  given  the  cancerous  mass  begins  to  contract 
and  shrink  and  continues  to  diminish  in  size.  This  is  more  marked 
in  some  cases  than  in  others,  the  growth  having  entirely  disappeared 
within  two  months.  The  treatment  should  be  repeated,  but  the 
time  and  dose  must  be  decided  upon  by  existing  conditions.    When 


546  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

the  pain  and  offensive  discharge  disappear,  the  patient's  general 
health  improves  rapidly.  This  even  occurs  in  some  patients  who 
are  in  a  toxic  condition  and  have  been  taking  morphine;  the  pain 
is  relieved  and  no  medical  ion  is  necessary.  In  some  cases  an  in- 
crease in  weight  is  observed  and  the  patients  are  restored  to  per- 
fect health. 

Many  observers  have  agreed  that  the  carcinoma  in  these  hope- 
less cases  disappears  locally,  and  the  patient  is  locally  or  clinically 
cured  in  from  one-fourth  to  one-third  of  the  cases,  but  when  there 
are  extensive  metastases,  the  treatment  is  only  palliative.  In  many 
of  these  cases  hepatic  metastases  have  taken  place  before  they  were 
referred  for  treatment.  Often  deep  metastases  can  not  be  determined 
by  physical  signs.  Nevertheless,  the  palliation  is  more  satisfactory, 
and  possibly  adds  from  four  to  six  times  to  the  life  of  the  patient. 
as  compared  to  any  other  palliative  measure,  and  even  hopeless 
cases  have  remained  well  more  than  three  years;  hut  space  does  not 
permit  giving  any  statistics. 

In  conversation,  one  of  the  leading  gynecologists  of  the  country 
said  that  a  vast  majority  of  the  cases  of  carcinoma  of  the  cervix 
that  consulted  him  were  inoperable,  and  then  he  considered  either 
removal  or  cautery  only  as  a  palliative  measure,  and  that  the  pal- 
liation A\as  of  very  short  duration  in  most  cases.  He  further 
stated  that  he  had  seen  cases  of  the  same  class,  Avhere  radium  was 
applied  either  as  an  adjunct  or  alone,  and  that  the  local  disease  had 
entirely  disappeared  in  some  instances,  and  that  a  few  remained 
free  from  symptoms  from  one  to  three  years. 

Frank,  in  an  article  published  in  the  Journal  of  C<nic<  r  R<  s<  arch . 
January,  1917.  advises  "that  all  operable  cases  be  subjected  to  a 
short  preliminary  treatment  by  radium,  followed  by  an  abdominal 
hysterectomy."  This  preliminary  treatment,  he  states,  should  be 
vigorous  and  of  short  duration,  with  the  object  of  sterilizing  the 
growth,  and  the  operation  should  be  undertaken  before  parametral 
scar  formation  takes  place  or  has  advanced  too  far.  If  it  is  too 
far  advanced  the  pelvic  connective  tissues  in  the  eases  operated 
upon  are  found  to  be  so  hard,  contracted  and  board-like  that  the 
ureters  could  nol  be  identified  or  pushed  away  from  the  uterine 
arteries.  In  view  of  his  observation,  Frank  deemed  it  best  not  to 
operate  until  the  lapse  of  three  weeks  because  the  growth  would 
not  be  sufficiently  cleansed  from  a  bacteriologic  point  of  view. 
Four  weeks  after  the  operation  radium  should  be  resumed. 

I  have  never  treated  an  early  case  of  cancer  of  the  uterus  be- 
fore operation  and  merely  mention  this  because  Frank  speaks  of 


RADIUM   AND   ROENTGEN   RAYS   IN    MALIGNANCY  547 

sterilizing  the  growth  by  heavy  radiation.  Another  point  which 
is  worthy  of  consideration  is  that  Frank  advises  operation  between 
two  or  three  weeks  after  the  radiation  and  not  five  or  six  weeks 
when  a  large  amount  of  connective  tissue  has  formed.  The  time  for 
operation  is  important  in  the  borderline  cases  if  anteoperative  radia- 
tion is  given.  The  time  for  operation  after  anteoperative  treat- 
ment is  not  only  determined  by  the  time,  but  also  by  the  amount 
of  radiation. 

Postoperative  treatment  of  uterine  carcinoma  is  an  important  field 
for  radium,  supplemented  by  the  roentgen  rays  from  without,  but 
it  is  usually  neglected  until  there  is  a  recurrence.  Of  course,  it 
is  difficult  to  estimate  the  exact  benefit  to  be  derived  from  post- 
radiation,  but  many  believe  they  increase  the  number  of  cures  by 
this  method  in  carcinoma  of  the  cervix.  It  is  only  a  question  of  a 
short  time,  until  gynecologists  will  advise  postoperative  radiation, 
the  same  as  is  done  by  most  surgeons  after  operation  for  carcinoma 
of  the  breast.  Many  of  those  employing  radium  are  depending 
on  radium  alone,  and  are  not  supplementing  it  by  the  roentgen 
rays. 

Experience  of  the  past  three  years  has  shown  that  we  can  not 
treat  successfully  with  radium  at  a  greater  distance  than  two  or 
maximum  three  centimeters.  It  has  been  universally  accepted  that 
cancerous  growths  can  be  promptly  and  also  apparently  permanently 
cured  at  this  depth  from  the  radium  tube.  However,  if  the  disease 
is  advanced  and  there  is  infiltration  of  the  growth  into  adjacent 
lymphatics,  the  cure  is  only  apparent.  The  local  growth  may  disap- 
pear, but  if  metastasis  takes  place  before  treatment  is  given,  it 
will  progress,  if  radiation  is  effective  only  for  two  to  three  cen- 
timeters from  the  tube,  without  regard  to  the  quantity  of  radium 
applied  or  to  the  length  of  time  it  is  applied.  Larger  quantities 
of  radium  have  been  tried  and  the  time  of  exposure  increased  so 
as  to  influence  cancerous  cells  at  a  greater  depth,  but  the  universal 
reports  show  that  not  much  success  has  been  accomplished  in  this 
direction.  The  overlying  tissues  were  damaged  beyond  recovery, 
regardless  of  the  kind  of  filters  employed.  The  rays  of  radium 
in  contact  with  the  growth  were  too  intense  where  it  entered,  and 
too  weak  at  a  greater  distance  from  the  tubes  than  two  or  three 
centimeters.  Placing  the  radium  at  a  distance  from  the  surface  so 
the  rays  would  be  nearly  uniform  at  the  point  of  entrance  and  at 
the  distance  required,  renders  the  radiation  too  weak  even  if  large 
amounts  are  employed.  The  same  objection  is  not  held  to  apply 
to  the  present  roentgen  tube  which,  when  powerfully  excited,  gives 


548  AFTER-TREATMENT    OP    SURGICAL    PATIENTS 

off  many  thousand  times  more  rays  than  any  quantity  of  radium 
any  one  lias  ever  used,  it  lias  been  estimated  that  with  92  grams 
of  radium  it  would  be  necessary  to  place  the  radium  at  the  same 
distance  in  order  to  obtain  at  a  depth  of  10  centimeters,  the  same 
intensity  of  radial  ion  as  with  the  roentgen  tube.  This  does  not 
mean  that  it  would  be  necessary  to  give  the  radium  in  five  to  ten 
minutes  as  we  are  doing  at  the  present  time  with  the  roentgen 
rays. 

It  has  been  found  that  radiation  will  destroy  cancer  cells  at  a 
depth  of  ten  centimeters  from  the  surface  of  the  skin,  and  the 
intensity  is  reduced  from  inn  to  L5,  thai  is  about  one-seventh  of  that 
on  the  surface. 

In  order  to  show  the  manner  in  which  gynecologists  are  taking-  up 
the  treatment  of  radium  in  uterine  cancel-,  the  following  is  quoted 
from  John  (!.  <  'lark's  paper.  "What  Do  the  Newer  Methods  of  Treat- 
ment offer  the  Patient  with  Malignant  Disease  of  the  Uterus?" 
I  New  York  Med.  Jour.  . 

"Basing  our  statemenl  upon  the  literature,  and  upon  our  own 
limited  experience  in  the  use  of  radium,  we  should  set  down  as 
definite  postulates  the  following  conclusions:  1  l"p  to  the  present, 
there  is  not  sufficient  evidence  in  favor  of  radium  to  justify  one 
in  using  it  as  a  substitute  for  surgical  measures  in  operable  eases. 
(2)  As  a  forerunner  to,  and  a  follower  up  of  an  operation,  it  is 
unquestionably  advisable.  :'>  In  operable  cases  it  should  in- 
variably he  tried,  for  apparent  cures  have  occurred  in  some  markedly 
advanced  cases,  and  in  those  cases  that  are  ultimately  cured,  there 
is  nevertheless  a  decided  amelioration  of  symptoms — in  many  in- 
stances, the  offensive  discharge  and  hemorrhage  completely  dis- 
appear. (4)  A  serious  disadvantage  in  the  use  of  radium  is  that 
il  occasionally  produces  ;i  widespread  necrosis,  leaving  vesical  and 
rectal  fistula*  in  the  wake  of  its  destructive  action.  This,  however, 
usually  occurs  only  in  advanced  cases  of  carcinoma,  and  need  not. 
therefore,  deter  us  from  the  use  of  the  remedy."' 

Local  injury  to  the  patient  will  seldom  occur,  it  seems,  if  the 
proper  amount  and  kind  of  filtration  is  used  and  if  the  dosage  is 
adapted  to  the  individual  patient.  We  know  thai  tissue  will  stand 
large  doses  of  radium,  if  not  too  often  repeated,  leaving  no  scar 
or  adhesions.  Radiation  carried  to  the  extent  of  severe  injury  of 
normal  tissue  may  defeat  its  own  ends.  The  tissues  can  he  more 
severely  inflamed  and  yet  make  a  complete  recovery  by  radium  sooner 
than  by  any  form  of  roentgen  therapy. 


RADIUM    AND    ROENTGEN    RAYS   IN    MALIGNANCY  549 

Clark's  remarks  could  be  applied  to  carcinoma  of  the  rectum, 
bladder,  and  prostate.  Operate  on  every  operable  case,  radiate 
all  cases  after  operation.  Some  surgeons  advise  against  operating 
on  borderline  cases  because  usually  they  can  be  clinically  cured 
by  radium.  All  advise  radiating  advanced  cases,  for  an  occasional 
cure  will  be  obtained,  and  some  can  be  made  operable.  Radium 
supplemented  by  roentgen  therapy  in  far  advanced  cases  will  give 
great  palliation,  but  a  cure  will  not  be  effected.  Some  of  these 
cases  are  clinically  cured  in  that  all  visible  signs  of  the  disease 
will  disappear,  but  the  patient  will  later  succumb  to  deep  metas- 
tases. 

The  amount  of  radium  element,  the  screening,  the  distance  from 
the  growth,  the  time  of  exposure  and  the  nature  of  the  tissues  to 
be  acted  upon  must  be  carefully  considered  when  deciding  upon  the 
dosage.  The  law  of  reaction  is  the  governing  factor  in  its  use, 
and  success  can  only  be  attained  when  the  radiotherapeutist  is 
familiar  with  his  agent,  and  knows  the  exact  pathology  and  extent 
of  the  disease.  He  must  also  know  the  limitations  of  radium,  and 
not  promise  a  cure  when  nothing  but  palliation  may  be  expected. 

There  is  a  difference  of  opinion  in  regard  to  the  technic  of  ap- 
plying radium  in  uterine,  rectal,  and  vesical  carcinomata.  Kelly, 
Koenig,  and  others  advise  the  use  of  large  quantities  of  radium, 
while  others  advocate  the  use  of  smaller  quantities,  applied  for  a 
longer  period.  All  have  generally  agreed  that  less  than  50  mil- 
ligrams of  the  element  should  not  be  employed  in  uterine  carcinoma, 
as  stimulation  of  the  growth  instead  of  destruction  might  occur. 
Pinch,  of  the  London  Radium  Institute,  where  large  cpiantities  of 
radium  are  advisable,  prefers  to  use  from  50  to  100  milligrams. 
Burma  and  many  others  have  come  to  the  same  conclusion.  What 
final  dosage  will  be  decided  upon  to  produce  the  best  results 
remains  to  be  seen,  but  in  reATiewing  the  literature,  it  appears  that 
many  have  decided  upon  doses  from  2000  to  4000  milligram  hours, 
to  be  given  within  the  first  week  or  ten  days.  The  dosage  must 
always  be  decided  upon  for  each  individual  ease.  Some  give  this 
amount  at  one  seance,  while  others  divide  it  up  into  six  or  eight. 
The  results  seem  to  be  about  the  same,  but  the  condition  of  the 
patient  possibly  should  determine  what  course  to  pursue.  If  used 
continually  until  a  full  dose  is  given,  it  is  advisable  to  remove  the 
radium  and  give  a  cleansing  douche.  The  treatment  is  repeated  in 
three  or  four  weeks,  according  to  the  indications. 

There  is  also  some  difference  of  opinion  in  regard  to  screening, 
but  all  agree  that  at  least  2  millimeters  of  lead  or  its  ecpiivalent  of 


550  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

brass  or  bronze  is  necessary.  The  latter  is  being  prepared  by  many, 
as  it  is  claimed  that  bronze  gives  off  less  secondary  radiation.  The 
metallic  tube  is  covered  with  sufficient  rubber,  gauze  or  other  sub- 
stance to  cut  off  the  undesirable  secondary  radiation.  One  mil- 
limeter of  pure  rubber,  covered  by  gauze  and  a  finger  cot.  answers 
this  purpose. 

The  distance  of  the  radium  from  the  growth  is  only  the  thickness 
of  the  filter,  but  this  must  be  taken  into  consideration  when  de- 
ciding upon  the  length  of  exposure,  as  well  as  the  amount  of  radium 
element.  During  the  past  year  some  of  those  purchasing  radium 
have  visited  me  and  they  seemed  to  think  all  they  had  to  do  was 
to  insert  the  radium.  They"  were  unfamiliar  with  a  radium  or 
roentgen  reaction  on  the  surface  of  the  skin  or  mucous  membrane, 
to  say  nothing  of  the  deeper  reaction.  They  would  start  in  about 
the  same  way  as  a  gynecologist  would  without  knowing  the  princi- 
ples of  aseptic  surgery,  expecting  to  learn  by  sacrificing  his  patients. 
Roentgenologists  who  have  had  experience  in  therapy  are  much  1  tet- 
ter qualified. 

I  can  not  too  strongly  advocate  that  radium  be  supplemented  by 
the  roentgen  rays,  feeling  sure  that  smaller  quantities  applied  locally 
with  proper'roentgen  therapy  from  without  are  equal,  if  not  su- 
perior, to  any  quantity  of  radium  ever  used  up  to  the  present  time 
so  far  as  the  end  results  are  concerned.  Kelly  uses  radium  at  a 
distance  of  two  to  five  inches  from  the  surface  in  large  quantities 
from  without,  in  the  same  way  as  many  are  using  roentgen  therapy 
from  a  Coolidge  tube.  Whether  bis  results  are  equal  or  superior 
remains  to  be  seen.  As  lighl  decreases  inversely  with  the  square 
of  the  distance,  the  tissue  would  be  rayed  more  uniformly  x\  it li  the 
source  of  energy  a1  s  or  in  inches  than  at  2  or  5  inches.  Besides, 
greater  areas  can  be  treated.  Although  the  better  method  of  treat- 
ment still  remains  to  be  determined,  most  of  us  who  have  treated  a 
number  of  cases  of  fibroids  will  expeel  more  from  the  combination 
of  radium  and  the  roentgen  rays  than  from  radium  alone,  or  when 
treated  by  any  other  method.  As  before  stated,  this  is  the  method 
which  is  carried  out  in  European  clinics,  and  many  of  us  have  wit- 
nessed their  results. 

Carcinoma  of  the  Rectum.-  -Results  obtained  by  the  use  of  radium 
in  carcinoma  of  the  rectum  vary  greatly,  and  can  not  be  compared 
with  the  results  obtained  in  the  treatmenl  of  carcinoma  of  the  uterus. 
Fficienl  amounl  of  radium  therapy  is  given,  a  proctitis  generally 
oceiii's.  which  is  very  troublesome  unless  a  colostomy  has  1 a  per- 
formed.    .Most  of  those  using  radium  in  the  treatmenl  of  carcinoma 


RADIUM    AND    ROENTGEN    RAYS    IN    MALIGNANCY  551 

of  the  rectum  advocate  colostomy  before  beginning,  or  within  one 
week  after  the  first  radium  treatment,  This  prevents  the  feces  from 
aggravating  the  radium  reaction,  and  avoids  the  tenesmus  which 
always  occurs  if  a  full  radium  treatment  is  given.  "Where  colostomy 
has  been  performed  and  larger  doses  of  radium  have  been  em- 
ployed, a  few  inoperable  cases  of  carcinoma  of  the  rectum  have 
been  apparently  or  temporarily  cured.  If  the  patient  will  not  con- 
sent to  having  a  colostomy  performed,  palliation  can  often  be  ob- 
tained by  the  use  of  radium;  that  is,  the  growth  will  be  inhibited 
or  reduced  in  size,  which  will  temporarily  relieve  the  threatened 
obstruction.  Pain  is  also  relieved,  either  entirely  or  partially,  but 
it  must  be  remembered  that  unless  a"  colostomy  is  performed,  tenes- 
mus might  occur  if  large  doses  of  radium  are  employed.  Of  how 
much  value  radium  is  in  the  treatment  of  carcinoma  of  the  rectum 
as  a  postoperative  procedure,  other  than  that  which  follows  colos- 
tomy, is  difficult  to  determine. 

The  symposium  on  "Cancer  of  Certain  Pelvic  Organs,"  read -be- 
fore the  Massachusetts  Medical  Society,-  June  9,  1915,  from  a 
clinical  standpoint,  should  be  studied  by  every  one  interested  in 
the  treatment  of  malignancy.  This  symposium  emphasizes  the  im- 
portance of  more  radical  operations  than  have  beenlieretofore  per- 
formed for  carcinoma  of  the  pelvic  organs,  or  else  it  suggests  the 
addition  of  radium  and  the  x-ray  or  some  unknown  treatment  be- 
fore it  can  be  said  we  are  able  to  cure  a  majority  of  cases  which 
can  be  diagnosed  clinically.  The  surgeons  who  took  part  in  this 
symposium  were  not  only  of  the  highest  rank,  but  each  had  spe- 
cialized and  directed  his  attention  to  only  one  of  the  pelvic  organs. 

In  this  symposium  Dr.  Daniel  Fiske  gave  the  statistics  of  the 
Harrison-Cripps  cases  to  show  how  absurd  it  is  to  talk  about  car- 
cinoma of  the  rectum  as  a  benign  condition.  The  statistics  are  as 
follows:  He  saw  445  patients  and  operated  upon  107;  of  these 
107  cases,  17  per  cent  died  from  the  effects  of  the  operation, 
and  40  were  alive  five  years  after  the  operation ;  that  is,  9  per  cent 
of  the  total  number  seen.  It  would  be  fair  to  assume  that  not 
more  than  5  per  cent  would  be  alive  at  the  end  of  ten  years. 

In  this  symposium  Dr.  Arthur  L.  Chute  states:  "The  story  of 
carcinoma  of  the  bladder  is  most  discouraging  when  we  consider 
the  small  number  of  cures  that  we  effect  by  means  of  operation. 
Just  enough  cases  remain  well  after  operation  to  allow  us  to  say 
that  cancer  of  the  bladder  is  not  absolutely  hopeless  and  to  spur 
us  to  renewed  effort  in  the  hope  that  when  we  have  a  clearer  un- 
derstanding of  the  condition,  our  results  will  be  better," 


552  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

If  it  were  possible  to  make  an  early  diagnosis  when  only  the 
mucous  layer  of  the  bladder  is  involved  it  would  seem  possible 
that  such  conditions  could  be  promptly  healed  by  radium.  A  few 
good  results  have  been  reported,  but  unfortunately  these  cases  are  usu- 
ally diagnosed  late,  and  it  is  more  difficult  to  apply  radium  to  the 
bladder  than  to  almost  any  other  organ  in  the  body.  The  danger 
of  setting  up  an  obstinate  cystitis  is  always  to  be  remembered. 
From  studying  the  lymphatic  supply  of  the  pelvic  organs,  it  is 
readily  seen  how  difficult,  if  not  impossible,  it  is  to  remove  the 
adjacent  glands  involved  at  the  time  of  operation,  no  difference 
how  radically  it  is  performed.  It  is  usually  impossible  to  remove 
all  the  glands  affected.  The  question,  when  operating,  is  if  the 
glands  are  affected  where  are  we  going  to  stop? 

Young,  in  discussing  the  uses  of  radium  in  the  treatment  of 
cancel-  of  the  prostate  and  bladder,  stnt.es  that,  while  it  is  not  his 
intention  to  speak  of  the  ultimate  results,  il  can  safely  he  stated 
that  truly  astonishing  results  have  been  obtained  in  some  cases; 
namely,  disappearance  of  obstruction,  shrinkage  and  great  soften- 
ing of  certain  cancers  of  the  prostate,  and  extensive  retrogressive 
changes  in  inoperable  cancers  of  the  bladder.  The  methods  devised  by 
Young  offer  a  new  fertile  field  of  therapeutics  in  a  class  of  nrologic 
cases  which  heretofore  have  been  almost  beyond  relief.  While  we 
do  not  as  yet  know  all  the  possibilities  of  cure,  we  do  know  that 
much  relief  can  he  afforded. 

Epithelioma. — The  term  "epithelioma"  is  not  altogether  clear  in 
the  minds  of  the  profession.  It  is  unsatisfactory  and  is  applied  to 
all  epithelial  growths,  semi-malignanl  or  malignant,  regardb  -  oi 
the  degree  or  situation.  This  has  accounted  for  a  diversified  opinion 
in  regard  to  many  innocent  Looking  lesions  which  in  time  will  show 
a  malignant  and  destructive  character.  Education  alone  will  teach 
the  value  of  early  recognition  when  the  treatment  is  easy  by  one 
application  of  radium.  .Many  patients  villi  lesions  of  this  type 
come  late  after  they  have  been  treated  by  superficial  caustics  and 
are  in  a  hopeless  condition.  Ii  is  to  he  remembered  that  true 
epithelioma  has  certain  pathologic  characteristics,  it  is  a  purpose- 
less proliferation  of  cells,  extending  beyond  normal  limits  and  in- 
vading adjacent  tissues,  especially  the  lymphatics,  with  slight  in- 
flammatory changes.  Most  text  hooks  have  classified  epithelioma 
under  three  varieties,-  superficial,  deep  and  papillary,  hut  it  means 
nothing  to  the  average  student  and  lie  leaves  college  with  a  vague 
idea  of  epithelioma,  except  complete  excision,  and  does  noi  recog- 
nize t  he  early  lesions. 


RADIUM    AND    ROENTGEN    RAYS    IN    MALIGNANCY  553 

It  is  astonishing  how  common  epithelioma  is  and  how  many  cases 
are  seen  in  the  large  clinics  who  have  never  consulted  a  physician 
and  the  disease  is  so  far  advanced  that  they  are  incurable.  Epi- 
thelioma, at  least  in  the  early  stages,  does  not  seem  to  cause  any 
alarm  among  the  inhabitants  of  a  community  or  even  among  the 
family  physicians.  The  disease  comes  on  so  slowly  that  often  no 
one  takes  any  notice  of  it  until  the  lesion  is  far  advanced.  After 
the  age  of  thirty-five,  all  persistent  lesions  which  are  constantly 
inflamed  and  scaly  or  show  any  degenerative  changes  should  re- 
ceive attention.  The  prophylactic  treatment  is  by  far  the  most 
important  and  necessitates  not  only  the  education  of  the  medical 
profession  but  also  of  the  laity  of  the  necessity  of  the  complete 
removal  of  all  excrescences,  such  as  warts  or  degenerated  moles ; 
the  removal  or  correction  of  any  irritation  to  the  skin  or  mucous 
membrane;  the  proper  treatment  of  cracked  lip,  persistent  spots 
of  eczema  and  leucoplakia.  Precancerous  changes  should  receive 
more  attention  by  the  physician.  He  should  hold  himself  responsi- 
ble for  any  of  his  patients  becoming  incurable,  especially  if  the 
epithelioma  has  been  of  long  duration. 

Present  day  results  in  the  treatment  of  epithelioma  are  much 
more  effective  than  in  the  early  days  of  radiotherapy.  In  the  past, 
whether  using  radium  or  the  roentgen  rays  in  the  treatment  of 
epithelioma,  there  have  been  the  two  methods;  namely,  the  fractional 
dose  and  the  massive  or  intensive.  In  the  early  days  of  radio- 
therapy, on  account  of  burns,  it  was  not  uncommon  to  give  very 
small  and  divided  closes  covering  a  long  time,  even  for  the  treatment 
of  small  epitheliomata.  Those  of  us  who  are  familiar  with  past 
results  will  remember  that  a  percentage  of  cases  was  permanently 
cured  and  some  cases  were  improved  up  to  a  certain  point  and  then, 
after  remaining  quiescent  for  a  period,  began  to  take  on  malignant 
tendencies  again,  and  that  some  advanced  cases  were  unaffected 
by  the  mild  treatment.  It  has  been  proved  that  the  long  radiation, 
and  often  repeated  mild  exposures,  are  an  ineffective  method  using 
any  form  of  radiation.  The  dose  may  be  divided  into  a  few  strong 
treatments,  but  not  into  an  unlimited  number  of  mild  exposures. 
It  is  a  fact  that  from  the  beginning  of  radiotherapy,  the  best  re- 
sults were  obtained  by  those  who  gave  strong  treatments,  and 
relatively  few  in  number.  When  treatment  is  given  by  a  method 
which  produces  no  visible  reaction  by  an  operator  who  is  afraid 
to  give  the  full  dose  promptly  and  continued  for  months,  such 
treatment  will  often  leave  the  tissue  degenerated  instead  of  leaving 
a  soft,  smooth,  and  pliable  scar.    When  such  is  produced  by  fault}" 


554  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

technic  this  degenerated  tissue  must  be  removed  surgically  and 
a  healthy  flap  turned  in  as  advised  by  Porter  in  treatment  of  chronic 
roentgen  ulcers  on  the  hands  of  some  of  the  operators. 

Further  treatment  with  radiation  will  bring  only  disappointment 
and  lessen  the  chances  of  a  cure.  Often  a  surgeon  is  not  dealing 
with  a  malignant  condition  and  if  so  it  is  usually  of  a  low  degree. 
It  is  often  difficult  to  convince  the  consulting  surgeon  of  this  fact. 
Epithelioma  is  carcinoma  of  the  skin  and  the  successful  method  of 
treatment  involves  the  complete  destruction  of  all  carcinomatous 
tissue.  It  has  required  clinical  experience  and  judgment  to  know 
when  this  has  been  accomplished. 

So  you  can  readily  see  the  operator  faces  ;i  serious  problem  in 
deciding  Hie  proper  form  of  radiation  and  dosage  for  each  case. 
The  operator  having  a  case  referred,  must  determine  the  type  of 
the  epithelioma,  its  situation,  extent,  the  danger  of  metastases  and 
the  form  of  radiation  which  is  the  most  effective  before  he  is  able 
to  give  a  prognosis.  Unless  lie  has  had  a  clinical  experience  as  veil 
as  being  able  to  produce  the  desired  reaction  at  the  proper  depth, 
he  is  unable  to  determine  whether  it  is  a  ease  which  can  be  cured 
by  radium  alone,  whether  other  adjunct  measures  are  necessary  or 
whether  radium  should  be  used  as  an  adjunct  to  some  other  form 
of  treatment. 

We  have  four  classes  of  epithelioma  in  regard  to  method  of  treat- 
ment :  first,  the  lesion  which  can  be  cured  by  one  application  of 
radium  with  the  proper  dosage;  second,  the  lesion  which  is  so 
situated  that  glandular  involvement  is  likely  to  lake  place  or  has 
already  occurred  and  the  roentgen  rays  should  be  employed  as 
an  adjunct  to  treat  the  adjacent  glands;  third,  those  cases  in  which 
the  local  application  of  radium  supplemented  by  the  roentgen  rays 
will  only  act  as  a  palliative  measure,  and  fourth,  those  cases 
in  which  excision  is  justified  to  be  followed  by  radiotherapy. 

A  marked  reaction  by  radium  heals  up  more  promptly  than  a  re- 
action of  the  same  degree  by  the  roentgen  rays.  This  is  a  valuable 
point    in   deciding  which    form  of  radiation   to  use  in  certain  cases. 

There  have  been  many  methods  of  treating  epithelioma  ranging 
from  the  internal  administration  of  arsenic  to  radical  surgical 
removal.  It  is  a  well-known  fact  that  superficial  caustics  have  been 
applied  to  cases  which  simply  increased  the  blood  supply  and 
stimulated  the  growth.  All  irritating  procedures  which  are  inert 
are  to  be  condemned  as  I  hey  arc  worse  than  no  treatment  at  all. 
as  before  stated  partial  removal  is  always  contraindicated.  This 
fact  was  realized  by  the  older  physicians  and  was  one  of  the  reasons 


RADIUM   AND   ROENTGEN   RAYS   IN    MALIGNANCY  555 

many  of  them  still  advise  their  patients  to  leave  an  innocent  looking 
lesion  alone  until  it  bothers  them.  The  results  by  radium  and  the 
roentgen  rays  are  changing  the  views  of  many  of  these  few  physi- 
cians. At  the  present  time,  among  many  of  the  best  physicians, 
there  is  a  strong  tendency  to  condemn  the  use  of  some  of  the  older 
and  inadequate  measures  which  have  kept  the  patient  from  seek- 
ing early  treatment.  The  principal  cause  of  failure  might  be 
attributed  as  much  to  an  inaccurate  technic  in  the  use  of  the  method 
employed  as  to  the  patient  going  late,  with  a  large  amount  of 
glandular  involvement.  Until  lately  the  value  of  a  legitimate,  con- 
servative and  nonsurgical  method  of  treatment  in  most  cases  has 
never  been  strongly  advocated.  As  a  result  of  the  tremendous 
strides  made  in  radiotherapy,  practically  all  the  late  surgical  au- 
thorities today  recognize  its  value  as  a  legitimate  method  of  treat- 
ment. They  agreed  that  radium  has  clinically  demonstrated  its 
power  of  changing  and  destroying  cancer  cells  more  or  less  per- 
manently with  the  least  possible  inconvenience  and  deformity  and 
the  best  possible  end  results. 

The  excision  of  an  epithelioma  is  justified  only  in  cases  which 
demand  the  removal  of  the  contiguous  lymphatic  glands  at  the 
same  time.  Except  for  cases  of  this  sort,  excision,  in  my  opinion, 
is  not  the  most  efficient  method  of  treatment.  Excision  neces- 
sitates a  sacrifice  of  a  large  amount  of  healthy  tissue.  With 
the  most  radical  operation  there  is  apt  to  be  left  outlying 
malignant  cells.  Therefore,  recurrences  are  common  after  excision. 
The  improvement  in  surgical  technic  and  the  recognition  of  careful 
handling  of  both  healthy  and  diseased  tissue,  as  well  as  the  wide 
extirpation  of  tissue  involved,  has  lessened  the  number  of  recur- 
rences. But  no  difference  how  wide  the  removal,  as  before  stated, 
it  is  not  wide  enough,  and  frecpiently  there  is  a  recurrence  in  the 
scar.  It  is  to  be  remembered  that  recurrences  after  removal  are 
regularly  more  malignant,  more  rapid  in  progress,  more  prone 
to  metastases  than  the  original  lesion.  Most  surgeons  realize  that 
an  incomplete  operation  is  as  powerless  for  palliation  as  it  is  for 
a  cure.  Partial  operations  are  therefore  contraindicated  in  any 
form  of  epithelioma  the  same  as  any  form  of  malignanc}*. 

Radium  and  the  roentgen  rays,  I  believe  should  always  be  con- 
sidered first  in  treatment  of  epithelioma,  because,  when  properly 
applied,  practically  all  epitheliomatous  tissue  can  be  made  to  dis- 
appear, and  there  are  fewer  recurrences  than  by  any  other  method. 
It  is  a  perfectly  legitimate  method  of  treatment  in  proper  hands 


556  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

but  is  a  method  liable  to  abuse  it'  it  is  not  restricted  to  its  proper 
field. 

Epithelioma  of  certain  locations,  on   account  (if  special  features, 

warrants  brief  separate  'description.  This  is  on  account  of  the 
nature  of  the  tissues  as  well  as  the  lymphatic  supply.  The  virulence 
of  an  epithelioma  increases  or  decreases  proportionately  with  its 
richness  or  poverty  of  the  lymphatic  supply.  In  o-ivinp-  a  prognosis 
of  an  epithelioma,  besides  location,  the  several  factors  to  be  con- 
sidered are  in  the  variety,  extent,  duration  and  rapidity  of  the 
process.  In  ;ill  instances,  the  earlier  the  treatment  is  instituted  the 
less  chance  is  there  of  a  recurrence.  In  many  superficial  forms. 
flu'  disease  if  neglected  is  slow  in  its  progress,  but  eventually  it 
will  become  dangerous  to  life  if  left  untreated.  In  the  earliest 
stages  when  the  disease  is  limited  on  the  face  and  of  the  superficial 
type,  treatment  is  almost  invariably  successful  and  permanently  so. 
Even  when  moderately  advanced,  the  results  are  usually  favorable. 
The  same  may  be  said  of  the  deep  seated  and  papillomatous  forms, 
if  not  of  too  lon<>  duration,  but  in  these  cases  glandular  involvement 
occurs  early.  Cases  in  which  marked  destruction  has  already  taken 
place  and  in  which  there  is  considerable  infiltration  of  the  sur- 
rounding tissues,  and  of  long  duration,  the  prognosis  as  to  a  per- 
manent cure  is  not  so  favorable,  and  particularly  so  if  the  glands 
are  invaded.  Rodent  ulcer  is  very  amenable  to  treatment  early. 
bu1  when  allowed  to  have  full  sway  and  cover  a  large  area,  it  is 
of  a  serious  nature  because  this  type  of  epithelioma  seldom  in- 
vades the  glands  but  destroys  everything  in  iis  way. 

Epithelioma  of  the  upper  part  of  the  face,  unless  it  has  involved 
cartilage,  or  bone,  is  more  amenable  to  treatment  than  in  any  other 
location.  In  the  early  cases  one  application  of  radium  would  usu- 
ally effect  a  cure.  Radium  is  one  of  the  most  effective  agents  in  the 
treatment  of  epithelioma  of  i lie  eyelids.  It  can  be  brought  in  eon- 
tact  with  the  lesion  and  there  is  little  or  no  danger  to  the  eye;  and 
if  the  cartilage  is  not  invaded,  it  requires  only  a  small  amount 
of  radium  to  effect  a  cure.  If  caustics  have  been  employed,  the 
cartilage  is  usually  involved,  and  it  is  much  more  resistant  to  treat- 
ment and  recurrences  are  more  likely.  The  cosmetic  results  are 
superior  to  any  other  agenl  unless  it  is  the  x-ray.  Frequently  when 
treating  an  extensive  lesion  you  will  expect  that,  if  the  lesion  is 
healed,  a  large  amount  of  deformity  will  resull  and  to  your  sur- 
prise there  is  scarcely  any  deformity  excepl  the  removal  of  the 
eye  lashes.     The  reason   for  this  is  that    the  resulting  scar  is  smooth. 


RADIUM    AND    ROEXTGEX    RAYS    IN    MALIGNANCY  00/ 

pliable,  and  not  thick  and  elevated  like  that  following  caustics  or 
even  a  cutting  operation. 

Epithelioma  of  the  nose  and  ear  is  easily  cured  if  the  cartilage 
is  not  invaded,  but  if  invaded  it  is  very  resistant.  The  ear  is  par- 
ticularly so,  and,  if  the  greater  part  of  it  has  been  removed  by 
pastes  or  caustics,  the  glands  are  usually  invaded  and  you  have  a 
very  difficult  if  not  a  hopeless  case  to  treat. 

Epithelioma  of  the  lover  lip,  however  innocent  in  appearance, 
often  shows  a  degree  of  malignancy  that  is  not  usual  in  other  situa- 
tions. It  seems  to  be  rather  a  regional  than  a  local  lesion.  The 
lymphatics  which  drain  it  are  early  invaded  and  the  results  in  the 
past  from  a  surgical  standpoint  have  been  far  from  satisfactory. 
However,  until  recently  the  routine  treatment  has  been  early  surgical 
removal  of  the  ulcer  and  lymphatics.  Until  the  introduction  of 
radium  and  the  roentgen  rays  there  was  no  alternative  treatment. 
Severe  caustics  would  occasionally  destroy  the  growth,  but  the 
resulting  scar  was  large  and  retracted,  and  the  percentage  of  re- 
currences was  very  high.  Even  after  operation  the  results  of  re- 
currences were  so  frequent  as  to  lead  the  more  careful  surgeons 
to  refer  these  cases  for  postradiotherapy.  Today  it  is  an  open  ques- 
tion whether  the  general  practitioner  is  justified  in  referring  these 
cases  for  radiotherapy. 

In  deciding  these  questions  let  us  consider  the  results  which  have 
been  accomplished  in  the  past  by  surgery  alone.  Murphy  has  shown 
us  that  in  early  surgical  removal  even  when  radically  performed,  a 
recurrence  takes  place  in  over  50  per  cent  of  the  cases  where  there 
are  no  palpable  glands  at  the  time  of  operation,  and  in  over  75  per 
cent  when  there  is  any  glandular  involvement  whatever.  I  believe 
better  results  can  be  obtained  by  radiotherapy.  There  are  a  num- 
ber of  radiotherapeutists  who  have  had  sufficient  experience  in 
epithelioma  of  the  lower  lip,  and  whose  results  justify  them  in  con- 
sidering radiation  a  perfectly  legitimate  method  of  treatment.  How- 
ever, the  cases  should  be  selected  and  treated  by  an  experienced 
radiotherapeutist.  Too  much  caution  can  not  be  directed  against 
inefficient  work  which  is  being  done  by  those  who  have  just  bought 
apparatus  and  have  received  instructions  from  manufacturers. 
Guided  by  these  experiences,  I  believe  that  radiotherapy,  by  the 
means  of  radium  and  the  modern  roentgen  tube,  at  present  consti- 
tutes the  best  routine  treatment  of  epithelioma  of  the  lower  lip. 
both  at  early  and  late  stages.  Experience  leads  me  to  a  firm  con- 
viction that  whatever  position  you  may  take  today  you  will  ul- 
timately agree  with  this   conclusion.      There  has  been  much  hag-- 


558  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

gling  surgery  of  lip  cancers  and  it  is  hoped  thai  this  chapter  may 
not  encourage  haggling  radiotherapy  in  the  same  field.  The  in- 
experienced, with  recklessness,  founded  on  ignorance,  may  burn  a 
case;  lmt  he  is  scarcely  more  dangerous  than  the  slightly  ex- 
perienced and  overcautious  radiotherapeutist  giving  insufficient 
dosage  which  may  stimulate  a  growth  to  activity. 

Epithelioma  of  the  back  of  the  hand  usually  responds  to  treat- 
ment, but  the  progress  is  not  so  favorable  as  with  the  ordinary  face 
cases  because  the  axillary  glands  are  often  early  invaded.  There- 
fore small  lesions  should  have  prompt  and  thorough  treatment. 
Xo  one  realizes  this  better  than  the  roentgenologists  who  have  had 
keratosis  on  their  hands.  Some  authorities  state  that  progress  in 
epithelioma  in  this  situation  is  slow  and  there  is  less  liability  of 
grave  ulceration  than  epithelioma  in  other  situations.  This  lias  not 
been  my  experience  entirely.  They  have  usually  been  slow  in 
progress,  but  the  lymphatic   glands  were   all  invaded  in  the  few 

ses  that  1  have  seen  at  the  time  they  were  referred. 

Epithelioma  of  the  genitals  is  always  a  serious  matter,  although 
with  the  proper  treatment  in  the  beginning  the  results  are  often 
successful.  Left  untreated  until  far  advanced,  palliation  is  all 
that  can  be  expected  from  any  form  of  treatment. 

Paget's  disease  or  eczematous  epitheliomatosis  of  the  nipple  is 
classified  by  most  dermatologists  under  epithelioma  or  carcinoma 
of  the  skin.  It  is  like  superficial  epithelioma,  the  onset  is  slow  and 
the  condition  suggests  an  eczematous  involvement  of  the  areola  of 
the  nipple.  The  process  begins  with  a  moderate  inflammation  ex- 
hibited as  redness  and  scaling  involving  the  nipple  areola.  Later 
the  surface  is  intensely  red  and  granulating,  exuding  a  copiously 
clear,  viscid  secretion  and  producing  subjective  sensations  of  heat 
and  burning  with  intense  or  moderate  itching.  "When  the  disease 
progresses,  cancerous  infiltration  of  the  breast  is  usually  recognized 
and  is  one  in  which  the  malignancy  is  usually  of  a  high  degree. 
In  the  Tear's  Progress  Medicirn  Surgery,  1015.  Murphy  called  at- 
tention to  Paget's  disease  and  stated  that  when  very  little  peri- 
mammillary  irritation  was  present  there  was  a  mortality  of 
over  00  per  cent  of  the  cases  even  when  submitted  to  surgical  op- 
eration. The  reason  for  this  is  that  the  patients  are  usually  first 
treated  for  eczema  and  are  not  given  proper  treatment  until  the 
disease  is  advanced.  They  try  almost  everything  and  yet  from  the 
very  first  it  was  cancer.  Pagel  's  disease  is  always  malignant  and 
should  be  called  Paget's  cancer. 


RADIUM   AND   ROENTGEN   RAYS   IN    MALIGNANCY  559 

Paget 's  disease  when  seen  early  I  believe,  can  be  as  successfully 
treated  with  radium  applied  locally,  supplemented  with  a  thorough 
course  of  roentgen  radiation  to  the  surrounding  breast  and  adjacent 
lymphatics,  as  by  operation.  I  have  treated  a  few  cases  and  whether  it 
was  my  good  luck  or  whether  the  cases  were  referred  sooner  than 
those  which  were  operated  upon,  my  results  have  been  very  grati- 
fying. This  corresponds  with  the  experience  of  many  others.  Be- 
sides the  patients  will  submit  to  radiation  long  before  they  will 
to  operation.  One  case  was  treated  eight  years  ago  and  the  patient 
has  never  had  any  recurrence  up  to  the  present  time.  If  these 
cases  were  referred  early  when  there  was  only  the  eczematous  con- 
dition present  and  treated  thoroughly,  the  results  would  be  rather 
uniformly  successful.  It  is  to  be  remembered  in  all  cases  there  is 
no  attempt  at  repair,  and  when  abandoned  to  its  course,  the  ul- 
timate result  is  a  profound  ulceration  with  the  destructive  effects 
most  noticeable  in  the  region  of  primary  invasion,  the  entire  breast 
becoming  cancerous  and  invading  the  lymphatics.  Paget 's  disease 
occasionally  affects  other  parts  of  the  body  such  as  the  scrotum, 
penis,  buttocks,  vulva  and  perineum,  as  well  as  other  parts  of  the 
body.  In  the  extramammary  cases  it  is  agreed  by  most  observers 
that  radium  and  x-ray  give  the  best  results.  It  is  to  be  remem- 
bered that  local  treatment  suggested  for  eczema  has  no  effect  on 
this  condition. 

While  it  has  been  shown  that  all  cases  of  epithelioma,  when  taken 
early,  can  be  successfully  treated  and  cures  effected  by  radio- 
therapy, it  should  be  borne  in  mind,  on  the  other  hand,  that  when 
cases  have  been  operated  upon  for  any  reasons  whatsoever,  the  op- 
erations should  be  supplemented  with  and  followed  by  treatment 
with  roentgen  rays  in  order  to  obtain  the  best  end  results. 

Cancer  of  the  Mouth  and  Throat. — In  the  treatment  of  malignancy 
of  the  mouth  and  throat  with  radium,  results  have  been  obtained 
in  a  sufficient  number  of  cases  to  entitle  its  use  to  consideration  in 
every  case,  whether  alone  in  small  lesions,  as  an  anteoperative 
procedure,  or  as  a  palliative  method  in  hopelessly  inoperable  cases. 
And  since  even  the  smallest  lesions  are  very  prone  to  recur  locally, 
and  the  adjacent  glands  are  so  early  invaded,  radiotherapy  should 
follow  surgical  removal  of  even  the  smallest  growth. 

In  all  examinations  of  the  mouth  and  throat,  precancerous  lesions 
such  as  leucoplakia,  should  always  be  looked  for  and  treated  promptly. 
Many  of  the  earlier  epitheliomata,  before  they  have  invaded  the 
deeper  tissues,  will  respond  to  one  application  of  radium.  It  is  al- 
ways advisable  to  have  a  consultation  with  an  experienced  laryn- 


560  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

gologisl  before  applying  radium,  and  the  gravity  of  innocent-look- 
ing lesions  must  no1  be  overlooked  or  treated  by  inert  methods. 
It  is  to  be  remembered  that  the  persistent  lesions  in  the  mouth  and 
throat  are  nearly  always  malignant  or  luetic.  Superficial  cautery 
seldom  removes  a  malignant  lesion  and  nearly  always  hastens 
metastases. 

"Whatever  method  is  selected  it  must  he  done  thoroughly.  It  is 
sad  to  state  that  so  many  cases  are  referred  after  superficial  cautery 
has  been  employed  and  the  groAvth  has  not  only  been  aggravated, 
but  deep  metastases  have  taken  place.  Many  physicians,  not  realiz- 
ing the  malignancy  of  these  lesions,  will  often  first  try  cauterization 
or  -dine  inert  mouth  wash,  allowing  the  disease  to  become  far  ad- 
vanced before  they  refer  their  patients  to  a  laryngologist  or  for 
radium  treatment.  There  is  no  place  where  it  is  more  important 
to  have  early  and  proper  treatment  than  in  the  mouth  and  throat. 
The  selection  of  the  method  depends  not  only  upon  the  location 
and  extent  of  the  lesion,  hut  also  on  the  experience  of  the  operator 
or  the  radiotherapeutist.  The  brilliant  results  obtained  have  in- 
duced  some  laryngologists  to  consider  radium  as  primary  treatment. 
But  if  good  results  from  this  treatment  do  not  follow  in  a  reasonable 
length  of  time,  then  the  advisablity  of  coagulation  or  operation  must 

he    considered. 

Roentgenization  of  the  lymphatic  glands  should  always  supple- 
ment radium  therapy.  The  object  of  roentgen  therapy  is  to  control 
and  destroy  metastases  in  the  adjacent  lymphatics.  The  glands 
should  he  treated  by  roentgen  therapy  in  the  early  cases  because 
mi  one  is  ever  able  to  tell  how  early  the  glands  are  invaded.  Ex- 
perience should  have  taughl  this  to  every  surgeon  and  laryngologist 
as  well  as  to  every  radiotherapeutist.  With  the  roentgen  rays. 
•■  areas  can  he  treated,  and  it  is  more  practical  than  radium. 
when  treating  the  entire  cervical  chain  of  glands.  But.  inside  the 
mouth,  the  results  of  the  roentgen  rays  can  not  he  compared  with 
those  of  radium,  since  the  latter  has  the  advantage  of  coming  in 
ch.se  contact  with  the  disease.  Then.  ton.  we  are  able  to  give  a 
much  heavier  dose  hy  radium,  even  producing  a  caustic  reaction 
which  will  heal  in  from  '2  to  4  weeks,  whereas,  if  this  dosage  were 
given  with  a  Coolidge  tube  of  the  ordinary  type  or  even  with  the 
one  which  has  been  suggested  for  cavities,  the  caustic  reaction  would 
not  heal  for  months,  or  probably  never.  A  slough  mighl  he  the 
result. 

In  some  cases  ii  is  advisable  to  follow  radium  treatment  by  electric 
coagulation.     The  advantages  of  electric  coagulation  are:   the  de- 


RADIUM    AND    ROENTGEN    RAYS    IN    MALIGNANCY  561 

struction  of  tissue  without  opening;  the  blood  ■  and  lymph  vessels, 
and  the  prevention  of  dissemination  which  might  occur  with  a  cut- 
ting operation.  The  large  amount  of  tissue  which  can  be  destroyed 
by  electric  coagulation  "without  hemorrhage,  is  an  item  of  great  im- 
portance, which  compels  serious  consideration  by  those  who  have 
treated  many  malignant  cases.  However,  a  preliminary  applica- 
tion of  radium  in  advanced  cases  is  always  of  great  service,  as  we 
have  no  other  agent  which  destroys  cancer  cells  to  the  same  extent, 
and  at  the  same  time  sterilizes  the  tissues. 

In  some  cases  after  radium  has  been  pushed  almost  to  the  caustic 
stage,  it  is  advisable  to  remove  the  growth  surgically.  I  have  seen 
a  few  hopeless  cases,  where  results  have  been  obtained  by  this 
method,  which  would  otherwise  have  been  impossible.  This  is  more 
often  true  where  the  malignant  growth  starts  in  the  tonsil  than  the 
buccal  mucous  membrane.  The  best  method  to  use  is  that  by  which 
all  the  cancer  cells  can  be  eradicated,  leaving  as  little  scar  con- 
traction and  deformity  as  possible,  because  a  recurrence  in  the  scar 
frequently  takes  place,  especially  if  it  is  contracted  and  irritated 
by  movement.  Therefore,  by  whatever  method  the  disease  is 
eradicated,  unless  the  resulting  sear  is  healthy,  pliable  and  free 
from  contraction,  it  should  be  removed  surgically. 

Sarcoma  in  the  nasopharynx  is  much  more  amenable  to  radium 
treatment  than  carcinoma.  Sarcoma,  even  in  cases  where  half  the 
throat  is  filled  with  the  growth,  will  frequently  disappear  in  from 
four  to  six  weeks  after  radium  treatment.  One  such  patient  whom 
I  treated  with  radium  has  remained  well  two  and  one-half  years. 
This  is  really  remarkable  because  his  throat  was  almost  filled  with 
a  mass  and  he  could  scarcely  swallow  or  speak  above  a  whisper. 
I  had  another  patient  in  whom  the  sarcoma  started  in  the  tonsil; 
three  operations  had  been  performed,  and  within  five  weeks  after 
the  last  operation,  there  was  a  recurrent  mass  which  filled  two- 
thirds  of  the  throat.  Within  six  weeks  after  radium  treatment, 
the  growth  had  entirely  disappeared.  Did  space  permit,  quite  a 
number  of  similar  cases  could  be  reported. 

While,  as  before  stated,  carcinoma  of  the  mouth  and  throat  is 
not  so  amenable  to  radium  as  is  sarcoma,  still  some  results  have  been 
obtained.  For  the  sake  of  description  superficial  lesions  may  be 
called  epitheliomata,  and  those  which  have  invaded  the  deeper  tis- 
sues carcinoma.  If  ulceration  is  confined  to  the  superficial  layers 
of  the  buccal  mucous  membrane  and  has  not  spread  to  the  teeth, 
one  application  of  radium  will  frequently  heal  the  lesion.  But  if 
the  ulceration  has  to  any  extent  invaded  the  muscle  tissue,  it  is 


562  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

very  resistant  to  radium  treatment.  Such  eases  should  be  given 
sufficient  radiation  to  produce  a  marked  reaction.  This  will  usually 
disappear  in  from  2  to  4  weeks  when  electric  coagulation  should 
be  employed  rather  Hum  a  repetition  of  radium.  This  will  usually 
heal  promptly  leaving  very  little  scarring,  and  no  contraction  of 
the  surrounding  1  issues.  If  the  gums  are  involved,  the  teeth  seem 
to  act  as  an  irritant,  and  the  cancerous  process  spreads  readily,  but 
if  they  are  extracted,  it  seems  to  only  aggravate  the  condition. 
What  has  just  been  stated  in  regard  to  the  buccal  mucous  mem- 
brane, will  apply  to  the  tongue,  except  that  the  muscle  tissues  are 
earlier  infiltrated  and  the  glands  are  earlier  invaded. 

Carcinoma  of  the  tonsil  and  nasopharynx  is  seldom  seen  until 
glandular  involvement  has  taken  place,  therefore,  the  results  ob- 
tained by  radium  in  this  location,  must,  as  a  rule,  be  considered 
from  a  palliative  standpoint.  It  is  advisable  to  o'ive  sufficient  radium 
to  produce  a  marked  reaction.  This  checks  the  growth  and  ster- 
ilizes the  surrounding  1  issues,  and  may  make  the  case  operable 
By  combining  radium  with  operation,  some  cases  have  been  at  least 
clinically  cured,  where  only  palliation  could  have  been  produced 
by  radiation  alone,  and  where  operation  by  itself  would  have  only 
made  the  condition  worse,  because  the  disease  could  have  been  but 
partially  removed. 

I  am  convinced  that  if  radium  were  employed  as  a  routine  pro- 
cedure, in  early  cases  often  no  other  treatment  would  he  neces- 
sary, and  in  advanced  cases  when  followed  by  coagulation  or  op- 
eration, better  end  results  could  be  obtained.  I  also  believe  more 
can  be  accomplished  by  raying  the  adjacent  lymphatics,  than  by 
removing  them  surgically,  because  if  the  glands  are  palpable,  op- 
eration seems  to  hasten,  rather  than  to  retard  the  malignant  process, 
since  it   is  very  seldom  that  all  the  cancerous  cells  can  be  removed. 

Sarcoma. — Sarcomata  do  well  under  treatment  of  both  radium 
and  the  roentgen  rays,  if  treated  before  dissemination  into  any  of 
the  internal  viscera  has  taken  place.  The  best  results  are  in 
lymphosarcoma,  where  the  results  seem  to  be  just  as  good  when 
treated  by  radiotherapy  alone,  as  when  the  growth  is  removed 
surgically  followed  by  the  roentgen  rays.  Sarcomata  in  other  lo- 
cations should  be  removed  surgically,  followed  by  radiotherapy.  It 
has  been  suggested  that  borderline  cases  should  have  anteoperative 
radiotherapy.  Under  radiation  Large  tumor  masses  gradually  di- 
minish in  size,  smaller  glands  disappear,  while  secondary  glands  also 
clear  up.  The  round  cell  variety  seem  to  be  the  type  of  growth  most 
easily  influenced   by  radial  ion,  while  the  spindle  variety  is  not  so 


RADIUM    AND   ROENTGEN"   RAYS   IN    MALIGNANCY  563 

readily  dealt  with,  probably  because  it  is  a  more  active  type  of 
growth. 

There  is  a  tendency  for  sarcomata  to  recur  within  a  year  or  so, 
and  often  in  the  deeper  parts,  particularly  in  the  lung's  and  me- 
diastinum. It  has  been  long  realized  that  nearly  all  sarcomata  recur 
within  six  months  to  two  years  after  operation.  Therefore,  after 
a  sarcomatous  growth  has  been  removed  surgically,  the  patient 
should  be  irradiated  over  the  whole  area  as  soon  as  possible  after 
the  operation.  It  is  of  extreme  importance  that  it  should  be  car- 
ried out  thoroughly.  The  difficulty  lies  in  the  fact  that  unless  great 
care  is  exercised  to  irradiate  the  whole  area  thoroughly,  experience 
has  shown  that  recurrence  often  takes  place  in  areas  which  have 
escaped  treatment.  The  whole  area  to  be  treated  should  be  mapped 
out,  and  central  points  selected  which  will  get  the  maximum  dose. 
The  results  of  prophylactic  treatment  are  encouraging,  the  patients 
are  less  pained,  the  movements  of  the  parts  are  facilitated,  and  the 
scar  is  less,  and  more  pliable  after  radiotherapy.  That  recurrence 
may  be  prevented  in  a  certain  number  of  cases  is  well  established, 
especially  in  view  of  what  we  know  occurs  when  early  recurrences 
are  treated.  It  is  logical  to  assume  that  remnants  of  the  disease 
left  in  the  wound  or  adjacent  tissue  will  disappear  in  the  reparative 
changes  set  up  in  the  surrounding  tissues  by  radium  or  the  roent- 
gen rays.  Sarcomata  will  frequently  recur  after  operation  under 
mild  treatment,  but  will  disappear  under  intensive  radiation. 


( '!  r APTER  LIV 

REAMPUTATIONS 

By  Willard  Bartlett  and  Walter  S.  Priest.  St.  Louis 

The  recent  war  has  made  necessary  a  much  greater  percentage 
of  reamputations  than  is  found  in  average  civil  practice.  In  con- 
sequence a  number  of  contributions  to  the  subject  have  appeared 
in  the  literature  within  the  past   Pour  years. 

The  complications  and  conditions  arising  after  a  primary  ampu- 
tation which  require  a  secondary,  or  reamputation,  can  be  deter- 
mined for  any  individual  case  by  the  attending  surgeon.  Reampu- 
tation is  necessary  and  intended  from  the  outset  where  conditions 
attending  the  primary  operation  arc  such  as  to  necessitate  the  "guil- 
lotine" or  "flush"  method  of  amputation  introduced  by  Fitz- 
maurice-Kelly.3  Such  conditions  are  occasionally  met  with  in  civil 
practice,  but  are  frequent  in  military  surgery  where  the  presence 
of  gas  gangrene  makes  such  a  procedure  necessary  to  life  saving. 
Another  condition,  seen  frequently  in  military  practice,  where  re- 
amputation  is  employed,  is  the  so-called  "trench  fool"  in  which 
simple  trimming  away  of  necrotic  tissue  is  done  until  healing  is 
established.-  Such  a  course  is  justifiable  inasmuch  as  such  lesions 
often  recover  to  a  surprising  extent,  and  save  tissue  that  would 
have  been  thoughl  necessary  to  remove  earlier.  In  the  end.  though, 
sucdi  stumps  are  either  had  functionally  or  do  not  heal  completely, 
hence  the  necessity  for  a  selected,  formal  reamputation. 

Whenever  possible,  reamputation  should  be  avoided  by  careful 
primary  amputation  with  proper  after-treatment,  as  reamputation 
is  accompanied  by  considerable  shortening  of  the  stum])  with  the 
possibility  of  greatly  lessened  function,  and  entails  no  little  hard- 
ship on  the  patient.  Merely  sawing  off  a  few  centimeters  of  bone 
at  the  secondary  operations  docs  nol  constitute  a  satisfactory  re- 
amputation. It  is  necessary  to  conduct  the  secondary  amputation 
along  some  of  the  approved  lines  for  primary  amputations  or  some 
modification  thereof.3 

There  are  some  general  considerations  to  be  taken  into  account 
in  planning  a  reamputation.4  The  skin  flaps  need  not  be  long. 
About  the  foot.  ;i  Svme  operation  gives  a  stump  adapted  to  a 
mechanical  ankle  and   is  end   bearing.     The  site  of  election   in   the 

56  4 


REAMPUTATIONS  565 

leg  is  the  middle  third  and  in  this  region  the  osteoplastic  method 
of  Bier  is  strongly  recommended  as  productive  of  the  best  results. 
Unless  the  distance  from  the  posterior  surface  of  the  thigh  to  the 
end  of  the  finished  leg  stump  is  at  least  five  or  six  centimeters,  a 
below-knee  artificial  limb  can  not  be  used,  and  amputation  should 
be  done  above  the  femoral  condyles.  Every  inch  of  the  thigh  until 
the  upper  third  is  reached  is  valuable,  and  unless  the  end  of  the 
stump  is  at  least  two  and  a  half  inches  below  the  lesser  trochanter, 
a  thigh  bucket  can  not  be  worn,  and  operation  through  the  neck 
of  the  femur,  or  at  the  junction  of  the  shaft  with  the  greater 
trochanter  with  intention  of  using  a  hip  bucket,  should  be  done. 
In  the  upper  extremities  all  fingers  possible  should  be  saved.  To 
within  three  inches  of  the  olecranon  process  all  of  the  forearm  is 
valuable.  Above  this  it  is  best  to  do  a  supracondylar  humeral  op- 
eration. All  of  the  humerus  is  valuable  and  the  shoulder  joint  is 
useless  unless  one  and  a  half  inches  of  the  humerus  below  the  an- 
terior axillary  fold  are  saved. 

As  soon  as  possible  following  operation  the  stump  should-  have 
massage,  passive  motion,  and  gradually  increasing  end  pressure  by 
means  of  roller  bandages  after  the  method  of  Hirsch.5  Psychically 
painful  stumps  have  been  observed  due  to  the  depressed  mental  at- 
titude of  the  patient,6  cheerfulness  and  optimism  on  the  part  of  the 
surgeon  as  to  the  eventual  usefulness  and  painlessness  of  the  stump 
as  well  as  careful  attention  to  provide  cheerful  surroundings  dur- 
ing convalescence  often  make  much  for  success.  In  cases  where  it 
is  known  from  the  outset  that  reamputation  is  to  be  done,  the  skin 
should  be  kept  from  retracting  by  strips  of  adhesive  and  weights  ar- 
ranged so  as  to  apply  gentle  traction  at  all  times. 

Osteoplastic  Reamputation. — As  the  art  of  surgery  advances,  more 
responsibility  is  placed  on  the  surgeon  in  securing  good  amputation 
stumps.  For  some  time  an  effort  has  been  made  to  perfect  stumps 
of  the  lower  extremities  with  respect  to  end  bearing,  in  addition  to 
making  them  capable  of  supporting  the  weight  of  the  body  through 
an  artificial  limb  applied  by  means  of  a  cuff  or  bucket  laced  around 
the  stump.  The  obstacle  to  the  successful  application  of  a  pros- 
thesis which  depends  solely  on  the  fit  of  the  cuff  is  readily  seen  when 
one  considers  the  atrophy  which  the  soft  tissues  are  certain  to  un- 
dergo. AVhile  such  an  artificial  limb  usually  serves  its  function 
well  when  first  applied,  the  gradual  decrease  in  diameter  of  the 
stump  makes  necessary  a  constant  readjustment  and  padding  of 
the  bucket  to  make  it  fit  snugly  enough,  and  eventually  a  good  fit 
may  be  impossible.    In  order  to  make  possible  the  placing  of  some 


566 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


of  this  strain  on  the  end  of  the  stump,  i.  e.,  to  make  the  stump  end 
capable  of  bearing  weight,  various  procedures  have  been  devised. 
It  has  long  been  recognized  that  the  heel  is  nature's  example 
of  a  properly  constructed,  -weight  bearing  stump.  Therefore,  ef- 
forts should  be  made  to  approximate  the  conditions  found  there  as 
nearly  ;is  possible.  To  accomplish  this  Bier  devised  the  osteoplastic 
method  of  amputation.  His  work  began  in  1891,  thirty-seven  years 
after  Pirogoff  introduced  the  subject.  Bier's7  first  contribution  to 
the  subject  appeared  in  1802,  but  the  type  of  "peg-leg"  for  which 
Ibis  operation  was  devised  is  now  seldom  seen.     His  next  contribu- 


Fig     186. — The  direction   of  skin   incisi 

lion,  the  one  with  which  we  are  concerned,  appeared  in  L8978  and 
dealt  with  amputations  in  the  middle  and  upper  thirds  <>!'  the  leg. 
The  technie  as  modified  by  Kocher9  and  Storp10  is  ns  follows:  an 
anteriomedial  elliptical  skin  incision,  the  lowesl  point  corresponding 
to  the  inner  surface  of  tin'  tibia,  is  made  and  carried  down  to  the 
muscles  and  periosteum  (Fig.  L86).  At  the  level  of  the  apex  of 
the  flap  the  periosteum  is  divided  transversely  across  the  medial 
surface  of  the  tibia  and  reflected  upward  sufficiently  to  permil  ;i 
small  wedge  of  thickness  not  quite  extending  to  the  marrow  cavity, 
to  be  removed   from  the  bone  thus  laid  bare  (Fig.  187).     The  skin 


REAMPUTATIONS 


567 


is  retracted  along  the  tibial  margins  and  a  rectangular  flap  of 
periosteum  marked  off  by  longitudinal  incisions  directed  proximally 
along  the  tibial  borders  (Fig.  188).  By  means  of  a  Gigli  saw  in- 
troduced into  the  wedge  previously  made,  a  rectangular  bone  flap, 
corresponding  to  the  periosteal  flap  already  outlined,  is  reflected 
by  sawing  parallel  to  the  inner  margin  of  the  tibia.  The  normal 
continuity  of  skin,  fascia,  periosteum  and  bone  is  disturbed  as  lit- 
tle as  possible.  When  the  desired  length  of  bone  flap  is  thus  sawed, 
it  is  severed  at  its  base  by  manipulating  the  saw  in  a  vertical  di- 
rection a  few  times,  then  breaking  it  across  with  an  elevator,  great 


Fig.    187. — Incision    through    skin,    deep    fascia    and    periosteum. 

care  being  taken  not  to  injure  the  periosteum.  The  periosteum  is 
then  stripped  up  about  a  centimeter  further  in  order  to  provide  an 
ample  periosteal  hinge  for  the  bone  flap.  Thus,  we  have  an  an- 
terior flap  consisting  of  skin,  fascia,  periosteum,  and  bone.  The 
muscles  are  now  divided  at  the  proper  level  parallel  to  the  skin  in- 
cision, and  the  tibia  divided  at  the  level  where  periosteum  leaves 
bone.  The  fibula  is  divided  at  a  somewhat  higher  level  and  is  not 
covered  by  a  bone  flap.  The  bone  flap  is  now  sutured  over  the 
end  of  the  tibia  by  means  of  its  periosteal  covering  (Fig.  189); 
the  vessels  secured  and  ligated;  the  nerves  divided  as  high  as  pos- 


568 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


sible;  the  muscles  sutured;  then  the  fascia  and  finally  the  skin, 
leaving  a  posterior  sear  extending  about  half  way  around  the 
stump.  It  is  well  to  place  the  three  layers  of  sutures  so  that  they 
are  no1  directly  superimposed  upon  each  other,  otherwise  a  hard, 
deep,  contractile  scar  will  result.  After  the  soft  tissues  over  the 
end  of  the  stump  have  undergone  fibrous  union,  a  well-formed 
stump  (Fig.  190)  capable  of  supporting  the  body  weight  or  a  part 
of  it  should  result. 

Other  osteoplastic  amputation  procedures  described11  are:     Ssa- 


Fig.    188.      Periosteum   and    bone   flap   elevated. 

banajeff's  femorotibial  amputation,  through  the  femoral  condyles  in 
which  a  bone  flap  from  the  upper  anterior  portion  of  the  tibia  is 
used;  the  Stokes-Gritti  supra-condyloid  operation  on  the  femur  in 
which  the  anterior  half  of  the  Longitudinally  divided  patella  with 
its  superior  tendinous  attachment  intact  is  used  as  the  bone  Hap. 
Chappie12  speaks  highly  of  this  operation  in  a  recenl  publication 
and  offers  a  modification  which  he  claims  overcomes  the  failures 
of  the  operation  which  have  caused  it  to  lose  favor.  To  these 
failures  he  ascribes  i  he  upward  pull  of  the  quadriceps  extensor 
tendon  and  also  the  mechanical  devices  used  to  keep  the  patellar 
flap   in   place.     He  does  away  with   both   these   features   by    freeing 


REAilPUTATIOXS 


569 


the  flap  from  all  tendinous  attachments  and  fixing  it  in  place  by 
periosteal  suturing. 

While  the  above  operations  were  designed  originally  for  primary 
amputations,  they  are  equally  applicable  to  reamputations  in  cor- 
responding regions. 

Osteoplastic  reamputations  can  likewise  be  carried  out  on  the 
thigh  with  the  prospect  of  equally  good  results  so  far  as  end  bear- 


Fig.   189. — Bone  flap  sutured  in  place  after  complete  division  of  all  structures  at  a  high  level. 

ing  is  concerned.  Modifications  of  Bier's  technic  should  be  used. 
Other  Methods  of  Reamputation. — Chappie13  of  the  British  Army 
who  had  a  large  series  of  cases  requiring  reamputation  following 
guillotine  amputations  done  at  the  front  where  conditions  were  far 
from  ideal  and  where  amputations  in  a  great  many  cases  were 
emergency  operations  in  the  truest  sense  of  the  word,  sets  forth 


570 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


some  factors  of  value  in  treating  such  cases.  It  must  be  remem- 
bered the  patients  were  in  a  bad  condition  generally  when  received 
and  their  stumps  presented  conical  granulating  and  suppurating 
ends  from  which  the  skin  and  soft  tissues  had  retracted  leaving 
various  lengths  of  exposed  bone,  often  sequestrated.  Not  only  were 
such  stumps  seen  following  the  guillotine  amputation,  but  it  was 
not  uncommon  for  patients  to  present  themselves  with  stumps  made 
by  one  of  the  regular  flap  methods  in  which  the  flaps  had  broken 
down  and  retracted,  leaving  a  similar  condition. 

In  brief,  the  technic  outlined  by  Chappie  as  described  by  Neve14 
is  as  follows:     (1)   Curette  granulating  surfaces,  paying  particular 


Fig.    190.      The   stump   with    flaps   sutured. 

attention  to  any  pockets.  (2)  Expose  the  bone  through  a  Longi- 
tudinal incision  on  the  outer  surfaces  of  the  stump.  (3')  Feel  peri- 
osteum back  without  using  longitudinal  incisions.  (4)  Cut  the 
bone  a1  the  lowest  possible  level  with  a  Gigli  saw.  (5)  Trim  away 
any  soft  tissues  injured  in  sawing,  free  the  skin  from  soft  tissues 
and  trim  ragged  edges,  avoiding  injury  to  subcutaneous  fat.  (6) 
Attend  to  hemostasis.  (7)  Introduce  a  purse  string  suture  into  the 
periosteum  infolding  it  as  a  cuff  over  the  end  of  the  bone,  thus 
preventing  the  formation  of  painful  spurs.     Suture   muscles.     In- 


REAMPUTATIONS  571 

troduce  tension  sutures  "staple-wise"  from  one  to  one  and  a  half 
inches  from  the  skin  edge  and  tie  while  skin  flaps  are  held  se- 
curely in  position.  Suture  the  skin  edges.  Drain  with  rubber  tubes 
at  each  end  of  the  incision. 

The  button  sutures  which  form  the  essential  part  of  this  technic 
are  composed  of  heavy  silk  threaded  through  oval  buttons  of 
vulcanite.  If  these  are  not  at  hand,  India  rubber  tubing  may  be 
used.  The  theory  on  which  the  importance  of  these  sutures  de- 
pends is  that  "tension  and  not  pus  is  the  enemy  of  union"  and 
that  even  if  the  skin  sutures  break  down  and  suppuration  occurs, 
a  sort  of  secondary  union  will  take  place  because  the  tension 
sutures  hold  the  skin  edges  closely  enough  together  so  that  when 
suppuration  ceases,  the  epithelium  bridges  the  narrow  gap  without 
difficulty.  If  suppuration  is  excessive,  drains  may  be  inserted 
between  the  skin  stitches.  These  stitches  do  not  serve  to  hold  the 
skin  edges  together  especially,  but  prevent  bulging  of  the  sub- 
cutaneous tissues. 

Advantages  claimed  for  this  technic  are:  less  loss  of  stump,  long 
skin  flaps  are  not  recpiired;  muscle  and  tendon  ends  are  kept  to- 
gether over  the  end  of  the  bone  which  ultimately  undergo  fibrous 
union  and  furnish  greater  motive  power  to  the  stump,  the  muscles 
do  not  retract  up  the  bone;  hematomata  are  prevented;  the 
vascularity  following  the  primary  operation  is  used  to  combat  sup- 
puration and  shorten  convalescence. 

Flapless  Method  of  Reamputation. — This  method  is  described  by 
Handley.10  Two  parallel  incisions  are  made  on  the  lateral  surface 
of  the  stump  at  the  desired  level  of  bone  division,  and  about  one 
third  the  circumference  of  the  femur  apart.  A  curved  forceps  is 
introduced  into  one  incision  and  worked  around  the  bone  until  it 
grasps  the  end  of  a  Gigli  saw  introduced  in  the  other.  It  is  then 
withdrawn,  bringing  the  end  of  the  saw  out  through  the  first  incision. 
The  saw  may  be  protected  by  tubular  guards.  The  direction  of 
the  saw  cut  is  always  from  the  main  arterial  trunks  so  there  is 
little  if  any  danger  of  injuring  them.  After  the  bone  is  sawed 
through,  an  assistant  grasps  the  end  of  bone  protruding  from  the 
end  of  the  stump  with  lion- jaw  clamps  and  exerts  traction,  while 
the  operator  detaches  the  muscles  with  the  aid  of  a  periosteal  ele- 
vator. Any  necrotic  or  calcified  tissue  is  trimmed  away  from  the 
end  of  the  stump,  and  after  attending  to  hemostasis,  the  skin  edges 
are  sutured  and  drained. 

Maryland10  uses  a  chain  saw  instead  of  the  Gigli  in  doing  Hand- 
ley's  operation,  and  also  makes  lateral  incisions  three  to  four  inches 


572  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

long  extending  to  the  bone.  A  silk  ligature  is  used  to  guide  the 
saw.  Carbolic  oil  dropped  on  the  chain  is  used  to  prevent  necrosis 
of  the  bone.  By  this  method  and  its  modification,  there  is  a  minimum 
exposure  of  fresh  surface  to  infection  in  septic  stumps  and  max- 
imum conservation  of  tissue. 

Apparent  Lengthening  of  an  Arm  Stump. — In  arm  cases  where 
it  is  not  possible  to  leave  a  stump  of  sufficient  length  to  provide 
for  the  attachment,  of  a  mechanical  arm.  Smith17  has  devised  a 
method  of  apparently  lengthening  the  stump.  The  operation  con- 
sists in  making  an  inverted  horseshoe  incision  into  the  axilla,  the 
ends  of  the  incision  being  well  within  the  borders  of  the  axillary 
space.  The  insertions  of  the  pectoralis  major  and  latissimus  dorsi 
arc  divided  to  about  one-half  their  length  distally,  the  arm  being 
held  in  the  abducted  position  meanwhile.  The  divided  portions  of 
these  muscles  are  then  sutured  high  up  into  the  axilla  and  the  in- 
cision (dosed  with  the  arm  still  in  the  abducted  position;  the  line 
of  incision  changing  from  a  "U"  to  a  "Y."  In  the  case  reported 
the  length  of  the  stump  was  increased,  functionally,  from  three- 
fourths  to  two  inches  and  allowed  the  successful  application  of  a 
prosthesis  controlled  by  the  stump. 

Kineplastic  Reamputations. —  In  suitable  cases,  reamputations  of 
the  upper  extremities  offer  a  fertile  field  for  the  application  of  the 
principles  of  kineplasty,  or  cineplasty,  as  it  is  sometimes  called, 
in  order  to  obtain  the  maximum  function  of  the  stum]). 

In  1896,  Vanghetti,  although  qo1  a  practicing  physician,  became 
interested  in  the  possibility  of  usini;'  1he  contractile  power  of  mus- 
cles and  tendons  of  amputation  stumps  to  activate  the  mechanism 
of  a  mechanical  prosthesis.  His  report  of  experimental  work  on 
animals  was  published  in  L8991S  and  the  following  year  Cici  first 
applied  in  a  practical  way  the  principles  set  forth,  using  them  in 
an  arm  amputation.  Later  in  the  same  year  Codivilla  demonstrated 
the  applicability  of  the  method  to  amputations  of  the  lower  ex- 
trem.i1  ies. 

The  idea,  although  described  in  some  of  the  works  on  surgery 
published  after  thai  time,  was  not  used  to  any  great  extent  until 
the  recent  war  furnished  such  a  quantity  of  material  concentrated 
in  favorable  institutions  under  conditions  permitting  a  careful  study 
of  its  merits.  Gaudiani19  in  this  country  and  Putti  of  Bologna 
and  others  have  recently  urged  a  wider  employment  id'  this  method 
in  reconstructive  work  and  in  reamputations  as  well  as  in  primary 
amputations.  Putti,  in  an  address  before  the  British  Royal  So- 
ciety,-" urged  that,  where  time  and  other  conditions  do   not   permit 


REAMPUTATIONS  573 

of  such  a  procedure  at  the  primary  amputation,  the  surgeon  should 
operate  in  such  a  way  as  to  make  the  future  application  of  kine- 
plastic  principles  possible.  To  this  end.  as  much  osseous  and  con- 
tractile tissue  as  possible  should  be  saved;  the  muscles  and  tendons 
being  kept  from  retracting. 

Besides  providing  for  the  transmission  of  motion  from  the  stump 
to  the  prosthesis,  a  simpler  and  firmer  means  of  attachment  of  such 
an  artificial  member  is  supplied. 

The  meaning  of  kineplastics  as  given  by  Yanghetti  is  "any  kind 
of  bloodless  or  operative  plastics  which  tend  to  economise,  restore, 
or  substitute  muscular  masses  which  can  be  employed  towards 
imparting  direct  and  voluntary  movements  to  an  artificial  limb." 
Needless  to  say  the  variety  of  operations  possible  under  this  head 
is  limited  solely  by  the  surgeon's  skill  and  ingenuity.  The  moving 
unit  or  units  so  obtained  are  called  by  Putti  "motor  flaps."  Any 
contractile  tissue  may  be  made  to  serve  as  such  a  unit  provided 
it  has  means  of  securing  nourishment  and  is  covered  by  normally 
functioning  skin. 

Certain  requirements  on  the  part  of  the  motor  flap  must  be  met. 
It  must  be  capable  of  withstanding  considerable  traction;  must 
be  painless;  must  be  of  such  size  and  shape  as  to  permit  the  applica- 
tion of  loops,  hooks,  cords,  and  other  mechanical  devices  for  con- 
necting it  with  the  mechanism  of  the  prosthesis.  A  covering  of 
intact  normal   skin  is   paramount   in   meeting   these   recpiirements. 

It  is  obvious  that  in  selecting  the  structures  to  form  such  a  flap, 
the  normal  anatomic  relations  and  physiologic  function  of  such 
structures  must  be  considered,  and  those  selected  which  are  most 
active  in  producing  the  desired  movements.  Tendons  are  especially 
desirable.  Where  these  are  not  available,  muscle  bundles  are  utilized 
by  constructing  tunnels  or  "buttonholes"  through  their  substance. 
"Where  possible,  antagonistic  groups  should  be  used  to  make  sepa- 
rate flaps.  Missing  essential  elements  may  be  supplied  by  various 
plastic  procedures. 

The  cases  suited  for  application  of  these  principles  are:  (1) 
primary  amputations  (most  desirable);  (2)  healed  stumps  prepared 
for  kineplasty  at  the  primary  operation;  (3)  certain  healed  stumps 
resulting  from  the  ordinary  methods  of  amputation.  Though  most 
applicable  to  the  upper  extremities,  the  method  may  be  used  in 
work  on  the  lower  extremities  to  secure  independent  and  voluntary 
control  on  the  part  of  the  stump  over  flexion  and  extension  of  the 
knee  joint  of  the  artificial  limb  after  thigh  amputation. 


674  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

Stumps  not  suitable  are  lliose  of  which  the  skin  is  adherent, 
scarred,  and  of  which  muscles  have  atrophied  to  such  an  extent  as 
to  be  only  slightly  contractile  or  which  have  ankylosed  joints. 

Willingness  and  patience  of  the  subject  to  train  himself  to 
use  the  new  member,  and  the  cooperation  of  a  mechanic  skilled  in 
making  artificial  limits  arc  necessary  adjuncts  to  complete  success. 
The  best  subjects  arc  those  between  twenty  and  thirty  years  of  age. 

Tfclinier1 — The  single  motor  flap,  the  double  motor  flap  and  the 
"plastic  club  motor"  illustrate  the  possibilities  and  variations  of 
the  method. 

Single  Motor  Flap  in  Amputation  Through  the  Arm. — A  cuff  con- 
sisting of  skin  and  subcutaneous  tissue  is  reflected  from  a  circular 
incision  four  centimeters  above  the  elbow  fold,  to  the  junction  of 
the  lower  and  middle  thirds  of  the  arm.  The  tendons  of  the  biceps 
and  triceps  are  severed;  the  nerves  cut  high;  the  soft  parts  re- 
tracted: a  cuff  of  periosteum  raised:  and  the  bone  sawed  across 
in  its  lower  third.  The  biceps  and  triceps  tendons  are  sutured  to- 
gether to  form  a  loop  extending  beyond  the  end  of  the  bone.  The 
periosteum  is  sutured  over  the  end  of  the  bone,  using  a  purse1  string. 
About  three  centimeters  Prom  the  border  of  the  skin  flap,  two 
longitudinal  incisions  about  five  centimeters  in  length,  one  on  the 
posterior,  one  on  the  anterior  surface,  are  made.  The  cuff  is  then 
brought  down  over  the  tendinous  loop  and  the  corresponding  edges  of 
the  buttonhole  incisions  sutured  together,  leaving  a  skin  covered 
hole  through  the  loop;  after  which  the  lower  edges  of  the  cuff 
are  sutured.  The  "buttonhole"  through  the  loop  is  kept  patent  with 
gauze  until  healing  and  cicatrization  are  complete.  It  is  well  to 
begin  traction  on  the  loop  as  soon  as  possible.  When  the  prosthesis 
is  fitted,  suitable  cords  passed  through  the  loop  connect  the  stump 
with  the  mechanism  of  the  hand,  so  that,  when  the  stump  muscles 
contract  the  fingers  are  flexed.  Following  relaxation  of  the  stump, 
the  fingers  are  relaxed  by  springs. 

V>y  suturing  the  tendons  of  the  extensors  and  flexors  of  the  fore- 
arm together,  a  similar  operation  can  be  performed  on  the  forearm. 

Double  Motor  Flap  in  Amputation  Through  the  Forearm. — A  cir- 
cular incision  through  the  skin  and  subcutaneous  tissue  is  made  and 
the  skin  allowed  to  contract.  At  this  new  level  the  muscles  and 
tendons  are  divided  circularly  to  the  bone.  Two  lateral  incisions, 
extendine;  proximally  for  about  five  centimeters  from  the  free  border 
of  the  skin,  one  along  the  radius,  the  other  along  the  ulna,  are  car- 
ried to  the  bone,  thus  forming  two  rectangular  flaps  of  skin.  Cor- 
responding musculotendinous   (laps  are   made.     These   flaps   are  re- 


REAMPUTATIONS  575 

tracted  and  the  bones  sawed  across  at  the  base  of  the  flaps  after 
providing  periosteal  coverings.  The  muscles  and  tendons  of  each 
flap  are  divided  in  equal  parts  and  the  two  portions  of  the  same 
flap  sutured  at  their  ends.  That  is,  the  procedure  with  each  flap 
is  essentially  the  same  as  with  the  single  flap  described  above.  In 
making  the  "buttonhole"  ring  in  each  flap,  the  corresponding  skin 
flap  is  folded  over  the  end  of  the  musculo-tendinous  loop.  The 
longitudinal  edges  of  the  skin  flaps  are  then  sutured,  and  temporary 
drains  inserted  at  the  base  of  each  flap.  Similar  after-care  as  de- 
scribed above  is  used.  By  connecting  one  of  the  motor  flaps  with 
the  flexor  and  the  other  with  the  extensor  mechanism  of  the 
prosthesis,  the  patient  has  voluntary  control  over  practically  all  the 
movements  of  fingers,  thumb  and  hand. 

Amputation  of  Forearm  Providing-  a  Plastic   Club  Motor. — De 

Francesco22  presents  the  following  adaptation  of  Vanghetti's  tech- 
nic.  After  amputating  in  the  usual  fashion,  longitudinal  incisions 
about  five  centimeters  in  length  are  carried  to  the  bone  over  the 
radius  and  ulna.  Through  these,  about  two  and  a  half  centimeters 
of  each  bone  is  removed  by  means  of  a  Gigli  saw,  leaving  about  two 
centimeters  of  each  bone  in  the  distal  end  of  the  stump.  The  end 
of  the  stump  and  the  longitudinal  incisions  are  then  sutured.  Dur- 
ing healing,  a  ring  is  placed  around  the  forearm  proximal  to  the 
bone  fragments,  and  traction  employed  to  prevent  contraction. 
When  healing  is  complete,  this  ring  is  replaced  by  one  of  padded 
hard  rubber,  which  is  held  in  place  by  the  knob-like  end  of  the 
stump,  and  suitable  cords  connect  the  ring  with  the  prosthetic 
mechanism.  The  fingers  are  flexed  by  contraction  of  the  stump 
muscles  and  passively  extended  when  the  muscles  are  allowed  to 
relax. 

A  tenoplastic  form  of  the  technic  has  been  devised  by  Vendrene,23 
and  an  osteoplastic  operation  for  using  the  rotatory  power  of 
humeral  stumps  has  been  suggested  by  Elgart.24 

Full  credit  is  due  Walter  S.  Priest  for  having  abstracted  all  the  lit- 
erature to  which  reference  is  made  in  this  chapter. 

Bibliography 

iFitzmaurice-Kelly :     Lancet,  London,  1915,  i,  15. 

2"Wiight:     Jour.  Roy.  Army  Med.  Corps,  1917,  xxviii,  259. 

3Wright :      Loc.  cit. 

4Huggins:     Lancet,  London,  1917,  i,  1917. 

sHirsch:     Deutsch.  med.  Wchnschr.,  1899,  p.   77G. 

^Corner:     Proc.  Eoy.  Soc.  Med.,  1917-18,  xi,  7. 

7Bier:     Deutsch.  Ztschr.  f.  Chir.,  1892,  xxxiv. 


.")(()  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

sBier:     Centralbl.  f.  Chir.,   L897,  p.  834. 

"  Kochii  :      Textbook  of  Operative  Surgery,  3rd   English  ed.,  1911,  Adam  &  <  'lias. 

Black,  London, 
lostorp:     Deutseh  Ztschr.  f.  Chir.,  xlviii,  p.  4. 
nKeen:      Surgery,  Its  Principles  and  Practice,  Philadelphia,  1909,  W.  B.  Saunders 

Co. 
isChapple:     Brit.  Med.  Jour.,  Aug.  17,  1918,  ii,  153. 
isChapple:      Ibid.,  Apr.  6,  1918,  i.  399. 

Lancet,  London,  July  27,  1918,  ii.  105. 
Brit.  Med.  Jour.,  Aug.  25,  1917,  ii.  242. 
i4Neve:     Brit.  Med.  Jour..  1917,  ii,  583. 
isHandley:     Brit.  Med.  Jour.,   1917,  ii,  244. 
ifiMaryland:      Brit.   Med.   Jour.,   1917,   ii.  304. 
iTSaiith:      Lancet,   London,   1918,   i,    706. 
i8"Vanghetti :     Arch.  Etaliano  di  Ortopedia,  1899,  svi. 
is>Gaudiani :     Ann.  Surg.,  19i8,  Iwii,  414. 
2oputti:     Lancet,   London,  1918,   i,  791. 

-'Keen:     Surgery,  Its  Principles  and   Practices,  Philadelphia,  l!n.">.     W.  B.  Saun- 
ders Co.,  \  i. 
Putti :      Loc.  '-it. 
( Jaudiani :     Loc.  '-if. 
Vanghetti :      Press.  Med.,  Ii»(i7.  xv.  210. 

Brit.   Med.  Jour.,   1918,  ii.  269. 
J.  de.  Chir.,  1908,  i,  192. 
Cici:     Press.   Med.,   1906,  xiv  7  15. 
Sauerbach:      Med.    Klin.,    1916,   p.    195. 
---'De  Francesco:      Arch.   f.    Klin.  Chir..  1009,   ,,.,  571. 
23"Vendrene :      I  o   Keen  :     Loc.  cit. 
2 1  Elera  rl  :     I  n  Ke<  □  :     I  iOC  cit. 


CHAPTEK  LY 

PEOCTOCLYSIS 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

The  administration  of  fluids  through  the  rectum  has  become  a 
very  common  practice.  When  one  considers  that  it  is  comparatively 
a  new  addition  to  the  means  at  our  disposal  for  making  postopera- 
tive patients  safer  and  more  comfortable,  one  is  no  less  amazed  at 
its  general  use  than  at  the  excellent  results  obtained  thereby. 

This  form  of  treatment  is  employed  as  routine  with  my  own  pa- 
tients, though  in  some  other  clinics  it  is  used  in  the  more  serious 
cases  only.  It  is  particularly  indicated  in  all  forms  of  peritonitis, 
in  toxemias  of  any  kind,  and  in  supplying  fluids  to  generally  de- 
bilitated and  dried  out  individuals,  where  the  stomach  is  not  availa- 
ble. Murphy,1  who  described  an  apparatus  which  was  successfully 
used  in  his  postoperative  cases,  was  the  pioneer  in  this  field,  and  to 
him  we  are  indebted  for  its  universal  use. 

The  giving  of  proctoclysis  is  indeed  a  very  simple  performance, 
but  must  be  carried  out  with  some  idea  of  the  laws  of  Nature, 
else  one  is  impressed  with  the  fact  that  she  rejects  ill-timed  en- 
croachments, and  the  fluid,  therefore,  is  not  retained.  Murphy, 
years  ago,  stated  the  well-known  fact  that  the  normal  large  in- 
testine is  moderately  distended,  and  that  its  mucosa  absorbs  water 
rapidly.  Any  overdistention,  especially  if  suddenly  produced,  causes 
spasm  of  the  musculature,  with  pain  and  expulsion  of  the  material. 
The  geueral  principles  upon  which  Murphy  founded  his  treatment 
have  not  been  changed,  although  improvements  have  been  made  in 
his  apparatus  from  time  to  time. 

His  instrument  consisted  principally  of  a  fountain  syringe  and  a 
large  curved  hard  rubber  or  glass  vaginal  douche  tip.  The  syringe, 
filled  with  warm  saline,  was  hung  eighteen  inches  above  the  pa- 
tient's hips,  and  the  curved  douche  tip  inserted  into  the  rectum. 
The  flow  was  then  started  by  releasing  a  pinch  cock  on  the  rubber 
tubing.  Fluid  was  thus  allowed  to  gravitate  to  the  rectum  in  drops, 
just  as  fast  as  they  were  absorbed;  the  flow  was  continued  as  long 
as  it  was  tolerated  or  deemed  necessary.  By  means  of  the  large 
tip  in  the  rectum,  gas  could  be  expelled  through  the  tubing,  to  the 

577 


578  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

reservoir,  and  thus  this  treatment  could  be  continued  several  days, 
without  very  great  inconvenience  to  the  patient. 

In  the  beginning  it  was  considered  highly  important  to  have  the 
fluid  a1  body  temperature  as  it  entered  the  bowel.  It  was  soon 
learned,  however,  that  with  such  an  apparatus  as  Murphy  used, 
the  fluid  could  not  he  maintained  at  an  even  temperature,  since 
heat  was  applied  to  the  reservoir  only.  Since  the  fluid  in  the  bowel 
was  constantly  being  absorbed,  there  was  a  continual  change  in 
the  height  and  temperature  of  the  fluid  in  the  reservoir.  In  order 
to  overcome  this  difficulty,  Elbreeht2  devised  an  arrangement,  by 
means  of  which  the  saline  could  he  heated  as  it  coursed  through 
the  rubber  tube.  By  this  means  the  amount  of  the  fluid  in  the 
reservoir,  as  an  important  factor  was  eliminated. 

Elbreeht 's  device  consisted  of  a  metal  heating  chamber,  which  was 
block-tin  lined,  contained  rubber  tube  connections  for  intake  and 
outlet  for  the  solution,  and  also  an  opening  for  an  electric  heating 
unit.  This  unit  was  connected  by  means  of  insulated  wires  to  an 
electric  socket.  It  could  he  used  with  either  alternating  or  direct 
currents.  The  metal  chamber  when  heated  by  electricity  was  put 
into  the  bed  villi  the  patient.  When,  however,  it  was  heated  by 
means  of  an  alcohol  or  gas  Lamp  it  was  placed  on  a  small  table 
at  the  side  of  the  bed.  The  fluid,  then,  was  heated  to  the  proper 
temperature,  just  before  it  passed  into  the  body. 

Elbreeht  also  devised  rectal  lips  of  different  sizes,  to  tit  the 
individual  case.  This  prevented  the  solution  from  escaping.  <>r 
the  rubber  tube  from  pulling  out.  Each  of  these  self-retaining,  hard 
rubber  rectal  tips  had  a  hole  in  the  center,  through  which  a  catheter 
could  he  inserted.  By  means  of  them,  an  ordinary  rubber  catheter 
could  he  used  instead  of  the  hard  rubber  vaginal  tip,  which  at  times 
exerted  too  severe  pressure  on  the  rectal  walls,  or  instead  of  the 
glass  tip,  which  was  easily  broken.  For  diminishing  the  lumen  of  the 
tube,  so  as  to  get  the  required  number  of  drops,  he  used  a  screw 
claiii]).  as  shown  in  Fig.  191,  page  589  instead  of  a  hemostat  or  the 
clamp  accompanying  a  fountain  syringe.  By  means  of  the  screw 
clamp,  the  saline  could  be  regulated  to  any  number  of  drops  per 
second. 

Elbreeht  V-  apparatus  did  not  improve  upon  the  one  first  used  by 
Murphy,  except  that  it  was  a  most  admirable  arrangement  for  keep- 
ing fluid  at  an  even  temperature,  it  was  also  somewhat  expensive, 
and  therefore  not  generally  used.  Wechsler3  used  an  apparatus 
which  by  heating  the  reservoir  alone  was  designed  to  nieel  the  same 
requirements  as  Elbrecht's.   It  was  similar  to  Murphy's  except  that 


PROCTOCLYSIS  579 

the  reservoir  consisted  of  a  large  irrigating  glass  container,  around 
which  was  placed  a  water  jacket.  Into  this  jacket,  hot  water  conld 
be  poured,  and  the  salt  solution  thereby  kept  warm.  When  the 
water  in  the  jacket  became  cold,  it  was  drawn  off  by  means  of  a 
stopcock.  This  arrangement  was  not  only  impractical,  but  also 
somewhat  expensive. 

Newman4  devised  a  funnel  arrangement,  which,  he  thought,  would 
overcome  the  expense  of  the  regular  proctoclysis  apparatus,  and 
yet  answer  the  same  purpose.  His  apparatus  consisted  of  a  large 
iron  ring  stand,  which  suspended  two  glass  funnels,  a  large  one 
to  act  as  the  reservoir,  and  a  smaller  one  to  allow  escape  of  gas 
from  the  rectum,  and  also  to  convey  the  drops  of  saline  from  the 
reservoir  to  the  rectal  tubing,  which  was  similar  to  that  employed 
by  Murphy.  A  metal  bar  placed  over  the  top  caused  the  saline 
to  drop  from  the  large  funnel.  This  bar  had  an  opening  in  its 
center,  and  at  this  point  the  nut  of  a  screw  was  placed.  A  thin 
rod,  which  was  connected  to  this  nut,  extended  to  a  rubber  stopper 
at  the  tip  of  the  funnel,  and  by  screwing  the  nut  drops  could 
be  secured  and  regulated.  An  electric  light  bulb  was  placed  in  the 
lower  funnel.  Saline  dropping  from  above  first  struck  the  light 
bulb,  and  was  then  conveyed  to  the  rectum  through  the  ordinary 
rubber  tubing. 

Newman's  was  the  best  apparatus  devised  to  allow  the  escape 
of  gas  from  the  rectum,  but  it  did  not  adequately  heat  the  saline. 
For  this  reason  it  did  not  become  very  popular. 

McLean5  devised  another  apparatus,  which  consisted  of  a  tin 
box  containing  a  two  quart  dish.  Under  this  was  placed  an  alcohol 
lamp  or  an  electric  light  bulb  to  keep  the  fluid  warm.  The  tip  of 
a  glass  funnel  which  extended  through  an  opening  in  the  box  was 
so  arranged  that  the  top  of  the  funnel  was  lower  than  the  two 
quart  dish  which  held  the  saline  solution.  Strips  of  gauze  one  inch 
wide  connected  the  reservoir  with  the  funnel  below.  A  four  ply 
strip  of  gauze  freed  fifty  drops  per  minute,  into  the  funnel,  and 
the  number  of  drops  desired  was  regulated  by  changing  the  size 
of  the  strip. 

An  apparatus  which  previously  was  devised  by  Saxon,0  combined 
the  good  points  of  those  which  have  been  mentioned,  and  in  addi- 
tion, had  a  thermometer  placed  in  continuity  with  the  rectal  tube, 
so  that  the  temperature  of  the  saline  could  be  ascertained  at  any 
moment.  The  reservoir  was  contained  within  a  tank,  permitting  it 
to  be  surrounded  with  hot  water,  which  when  cold  could  be  drawn 
off  by  means  of  a  stopcock,  and  hot  water  added.     A  small  glass 


"i^11  AFTER-TREATMENT    OF    SURGK  AL    PATIENTS 

cup  on  a  glass  "y"  tube,  served  for  an  outlet.  The  objection  to 
this  apparatus  was  that  it  could  not  be  conveniently  carried  from 
one  patient  to  another.  Babler,7  therefore,  devised  a  very  simple 
apparatus,  which  consisted  of  two  glass  jars  and  rubber  connections. 
The  jar  containing  the  saline  was  placed  in  the  other  larger  jar, 
which  contained  hot  water.  The  rectal  tube  and  tip  were  the  same 
as  used  by  Murphy.  The  outlet  for  gas  consisted  of  another  rub- 
ber tube,  which  was  connected  by  means  of  a  "y"  glass  tube  with 
the  main  rectal  tube,  and  was  held  by  means  of  a  bent  glass  tube. 
to  the  side  of  the  largest  glass  jar.  The  rectal  tube  communicated 
directly  with  the  saline  solution  in  the  reservoir  by  means  of  bent 
glass  tubing.  If  necessary,  the  jars  could  be  replaced  by  any  sort 
of  vessels  and  this,  with  the  small  amount  of  tubing,  made  the  ap- 
paratus desirable,  but  the  number  of  drops  could  not  be  counted, 
and  the  amount  of  fluid  going  into  the  rectum  could  not  be  ac- 
curately known. 

Lawson,8  one  year  previous,  in  order  to  determine  the  rapidity 
of  flow,  used  an  ordinary  medicine  dropper,  which  fitted  tightly  into 
the  center  of  a  rubber  stopper.  This,  in  turn,  fitted  into  the  top  of 
a  barrel  of  a  urethral  sa  ringe.  This  device  did  not  allow  gas  to 
escape  from  the  rectum,  so  Dewitt."  three  years  later,  employed  a 
similar  arrangement,  but  simply  punched  holes  in  the  stopper.  This 
then  proved  an  efficient  instrument. 

Many  other  appliances  were  devised,  but  none  seemed  perfectly 
satisfactory.  Apparently,  all  operators  were  agreed  that  the  gravity 
method  was  the  best.  i.  e.,  the  reservoir  should  not  stand  more 
than  eighteen  inches  above  the  hips.  It  was  also  generally  conceded 
that  continuous  proctoclysis  was  better  than  intermittent,  since 
too  often  inserting  even  the  simplesl  rectal  tube,  would  cause  ir- 
ritation in  the  majority  of  the  rases.  The  apparatus  of  Lawson, 
and  others  who  employed  funnels,  overcame  the  error  of  being 
unable  to  see  how  much  fluid  entered  the  re. -turn,  and  the  expelled 
Lias  was  also  easily  taken  care  of.  bu1  none  of  these  methods  fully 
met  all  the  obstacles  encountered  in  giving  fluid  per  bowel. 

It  seemed  to  be  the  prevailing  opinion  that  the  fluid  should 
be  at  body  temperature  when  it  entered  the  body,  in  older  to  be 
absorbed  more  readily,  and  most  of  the  devices  were  made  with  this 
point  in  view.  It  was  not  considered  necessary  to  have  tin1  fluid 
warm  in  order  for  it  to  lie  nonirritative  or  absorbable.  Considering 
the  universally  good  results  which  followed  the  application  of  this 
treatment,  regardless  of  the  method  used  in  applying  it.  one  is  not 
surprised  at  Weeks'10  statement,  for  without  doubt,  in  mosl  instances, 


PROCTOCLYSIS  581 

the  fluid  was  cold  by  the  time  it  reached  the  rectum.  In  our  own 
cases,  we  have  observed  no  difference  in  the  absorption  of  the  fluid, 
whether  warm  or  cool,  and  we  feel  this  is  not  an  important  point. 
However,  we  try  to  have  the  fluid  warm  in  the  reservoir,  in  order 
not  to  chill  the  patient. 

The  apparatus  which  we  employ,  combines  all  the  good  points 
mentioned  above.  It  consists  of  an  ordinary  irrigating  can,  which 
holds  one  quart  or  more  of  fluid.  The  water  which  is  used  for 
the  injection  is  poured  into  the  can,  and  a  temperature  around 
110°  is  maintained,  by  placing  a  bottle  full  of  hot  water  into  the 
water  to  be  used.  The  outlet  of  the  irrigating  can  is  connected,  by 
means  of  rubber  tubing  one-half  inch  in  diameter,  with  a  glass 
dropper,  and  this  latter  connects  with  the  arm  of  a  "y"  glass  tube. 
The  other  arm  of  the  "y"  connects  with  rubber  tubing,  which 
serves  as  an  outlet  for  the  gas,  and  suspends  from  the  top  of  the 
reservoir  by  means  of  curved  glass  tubing,  which  is  covered  by  the 
rubber  tube.  The  foot  of  the  "y"  connects  with  a  four  foot  rectal 
tube,  at  the  end  of  which  an  ordinary  No.  32  French  catheter  is 
attached  by  means  of  a  short  glass  tube.  The  catheter  is  greased 
well  with  vaseline,  and  inserted  six  to  eight  inches  into  the  lower 
bowel.  It  is  held  in  place  by  means  of  adhesive  strips  adhering 
to  the  buttocks.  The  screw  clamp,  which  is  placed  immediately 
above  the  visible  dropper,  regulates  the  flow  perfectly.  In  in- 
stances where  we  are  unable  to  secure  the  regular  dropper,  or  a 
"y"  tube,  we  employ  Weeks'  method,  which  in  the  main,  consists 
in  letting  the  water  drop  from  the  reservoir  into  a  funnel,  which 
connects  with  the  rectal  tubing.  The  drops  are  formed  by  utilizing 
the  screw  clamp.  If  this  too  can  not  be  had,  a  piece  of  gauze,  hang- 
ing from  the  solution,  may  be  so  employed  as  to  allow  the  fluid  to 
drop  into  the  funnel.  The  use  of  the  funnel  is  as  useful  a  method 
as  our  regular  apparatus.  It  is  cheaper,  simpler,  and  has  other  ad- 
vantages. The  funnel  can  be  utilized  in  giving  enemas  to  relieve 
gas  pains  or  to  remove  collections  of  fecal  material.  Keinsertion 
of  the  rectal  tip  or  catheter  is  not  so  often  necessary  when  using 
this  apparatus.  If  at  any  time  the  bowel  does  not  tolerate  the 
fluid,  the  funnel  can  be  taken  out  of  the  hanger  and  the  overflow 
in  the  rectum  is  syphoned  off.  This  method  is  particularly  useful 
in  children,  since  from  stoppage  of  the  tube  gas  collects  more  readily, 
and  the  bowel  is  more  irritable  than  in  adults. 

Physiologic  saline  solution  was  first  considered  by  the  pioneers 
in  this  field  as  the  proper  fluid  for  proctoclysis,  and  even  today  is 
used  extensively.     It  is  prepared  by  placing  8.5  grams  of  sodium 


582  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

chloride  in  a  liter  graduated  flask,  and  then  adding  sterile  distilled 
water  until  the  1000  c.c.  mark  is  reached.  A  very  common  and 
comparatively  accurate  method  is  simply  adding  two  level  tea- 
spoonfuls  of  fine  table  salt  to  one  quart  of  water. 

Unfortunately  this  solution  has  attained  the  name  "normal  salt 
solution."  and  has  become  so  fixed  in  the  minds  of  the  majority  of 
the  medical  profession,  that  the  fallacy  is  not  recognized.  A  normal 
salt  solution11  consists  of  the  atomic  weights  of  sodium  and  chlorine, 
23  and  35.46,  respectively,  dissolved  in  a  liter  of  pure  water.  It 
is  made  by  placing  58.46  grams  of  sodium  chloride  in  a  graduated 
liter  flask,  and  adding  pure  water  up  to  the  1000  c.c.  mark.  Thus 
a  physiologic  salt,  (that  which  is  always  used)  and  a  normal  salt 
solution  are  entirely  different  solutions.  The  former  is  an  .85  per 
cent  saline  solution,  while  the  latter  is  .5846  per  cent  salt  solution. 
h  would  he  quite  a  serious  mistake  to  order  "normal  salt  solution." 
meaning,  all  the  while,  the  physiologic  solution,  and  for  this  reason 
we  feel  justified  in  calling  attention  to  this  extremely  common  error. 

The  method  of  preparing  "normal  saline  solution"  was  recently 
investigated  by  Trout,  who  studied  the  methods  employed  by  232 
different  hospitals  and  found  that  they  "varied  from  the  most 
careful  attention  to  minute  details,  i.e..  that  the  fluid  contained 
potassium,  calcium,  and  sodium  chloride  in  varying  proportions, 
filtered  and  sterilized,  to  the  simple  placing  of  two  teaspoonfuls  of 
table  salt  to  one  quart  of  tap  water."  A  teaspoonful  of  salt,  as 
Trout  says,  may  he  anything  "from  L15  grains  to  270  grains,  de- 
pending upon  whether  it  is  heaping  or  level."  Considering  the 
amount  of  saline  which  is  given  at  times  per  rectum,  the  patient, 
under  these  circumstances,  would  he  forced  to  take  as  much  salt 
as  is  utilized  as  a  condiment  by  a  normal  person  in  a  month. 

There  can  he  no  doubl  that  under  many  circumstances,  large 
amounts  of  saline  administered,  promiscuously,  as  is  so  often  done, 
are  injurious  to  the  tissues  of  the  body.  Had  results  have  followed 
its  injudicious  use  in  postoperative  cases,  with  weakened  hearts, 
and  diseased  kidneys.  To  this  class  of  patients,  Willmoth12  would 
add  those  threatened  with  sudden  death,  dilated  right  heart,  pul- 
monary edema,  apoplexy,  or  arteriosclerosis.  So  often,  patients 
with  some  kidney  lesions,  and  even  on  a  salt-free  diet,  are  given 
the  routine  saline,  after  some  operation  has  been  performed.  We 
can  not  reconcile  such  a  procedure.  Bvans13  called  attention  to  the 
recklessness  with  which  saline  has  been  given  in  late  years.  He 
stated  that  "one  can  not  fail  to  he  impressed  with  the  danger  of 
such  a  procedure  in  postoperative  patients,  in  whom  saline  solution 


PROCTOCLYSIS  583 

is  given  without  previous  knowledge  of  the  condition  of  the  blood 
pressure,  the  ability  of  the  heart  to  handle  large  amounts  of  saline 
successfully,  or  the  functional  capacity  of  the  kidneys  to  excrete 
the  large  amount  of  chloride  thus  forced  upon  them."  He  also, 
rightfully,  stated  that  patients  have  died  due  to  the  use  of  saline 
alone.  Such  cases  usually  escape  reporting,  since,  as  he  says  the 
cause  of  death  is  problematic,  and  since  the  saline  is  used  in  grave 
surgical  emergencies,  the  death  is  attributed  to  other  causes.  When 
one  considers  the  numerous  ways  the  solution  is  prepared,  and  yet 
in  each  instance  the  physiologic  salt  solution  is  the  result  which 
all  are  striving  for,  it  would  be  impossible  to  determine  the  count- 
less number  of  patients  suffering  from  the  deleterious  effects,  from 
more  or  less  poisoning  due  to  overdosage  of  this  substance.  Actual 
death  from  saline  given  per  rectum  has  been  cited  in  a  few  in- 
stances in  the  literature.  In  a  case  reported  by  Brooks,14  salt 
solution  was  used  after  an  ordinary  appendectomy,  the  nurse  em- 
ployed a  stock  solution  of  sodium  chloride  in  preparing  the  saline 
to  be  used  as  proctoclysis,  and  gave  the  patient  one  and  one-half 
liters  of  the  solution  in  two  doses,  as  was  ordered.  The  poisoning 
which  resulted  from  the  nine  ounces  or  more  of- salt,  which  he  re- 
ceived, soon  produced  death  of  the  patient.  Campbell15  reported 
a  case  in  which  a  saline  enema  was  advised,  in  a  case  of  "worms." 
The  patient,  a  boy  five  years  old,  received  one  pound  of  salt,  in- 
stead of  a  tablespoonfnl.  in  a  quart  of  water,  as  was  advised.  In 
five  to  ten  minutes,  the  child  complained  of  intense  thirst  and  pains 
in  the  head.  Vomiting  occurred  soon  after  this  and  was  followed 
by  purging.  Within  one  and  one-half  hours  he  was  unconscious, 
and  died  in  convulsions  five  hours  from  the  time  he  was  given 
the  enema  by  his  mother.  Evans  cited  a  case  of  poisoning  due  to 
saline  proctoclysis.  This  patient  was  operated  upon  for  carcinoma 
of  the  uterus.  "Normal  saline  solution"  was  ordered  as  continuous 
proctoclysis,  and  the  nurse  gave  five  quarts  of  this  fluid  within 
eight  hours.  The  pulse  rose  suddenly  to  148  per  minute,  became 
irregular  and  weak,  and  soon  the  patient  became  stuporous.  By 
discontinuing  the  saline,  and  by  using  stimulants,  the  patient,  for- 
tunately, was  revived.  Sippel16  reported  a  death  from  saline  infu- 
sion in  which  three  liters  of  a  physiologic  salt  solution  were  given 
after  decapsulating  the  kidney  for  anuria.  The  anuria  was  relieved 
by  the  operation,  but  quickly  returned,  following  the  saline  infusion, 
and  resulted  in  a  fatal  termination  of  a  normally  progressing 
surgical  convalescence. 


584  AFTER-TKEATMENT   OF    SURGICAL   PATIENTS 

It  is  a  well-known  fact  that  sodium  chloride,  though  the  least 
toxic  of  the  metal  chlorides,  is  exceedingly  poisonous,  when  given  in 
large  amounts.  Joseph  and  Meltzer,17  a  number  of  years  ago.  showed 
that  3.7  grams  per  kilo  of  body  weight,  was  sufficient  to  kill  healthy 
animals.  In  Sippel's  ease  28  grams  of  sodium  chloride  were  given, 
and  in  Brook's  case  135.  Normally,  the  body  only  excretes  ten  to 
fifteen  grams  and  to  add  even  more  than  this  amount  to  the  already 
overloaded  kidneys,  could  hardly  be  expected  to  end  otherwise 
than  badly  for  the  patient. 

Trout18  recently  experimented  with  plain  tap  water,  and  physi- 
ologic salt  solution  per  rectum.  The  salt  solution  contained  .§%  to 
.!)',  sodium  chloride.  In  over  two  thousand  cases,  one  hundred 
and  twenty-one  complained  of  thirst  in  spite  of  large  amounts  of 
fluid,  which  were  yiven.  Of  these  cases  one  hundred  and  twelve 
received  the  salt  solution  only,  and  in  this  number  several  com- 
plained of  having  salty  taste  in  the  mouth,  though  they  did  not 
know  they  were  getting  this  mineral.  lie  states  he  would  no  more 
consider  giving  salt  water  by  rectum,  than  he  would  giving  it  by 
mouth,  when  the  patient  required  fluid  to  quench  his  thirst.  I 
heartily  agree  with  Trout,  and  my  cases  never  get  salt  solution  as 
protoclysis.  1  give  instead  a  solution  containing  glucose  '■'>' '<  and 
sodium  bicarbonate  5',  in  tap  water.  T  give  large  amounts  in  eases 
where  it  is  needed,  even  surpassing  nine  quarts  in  twenty-four  hours, 
as  given  at  first  by  Murphy.  The  solution  is  kepi  going  for  a  week 
at  a  time,  niuht  and  day,  in  severely  toxic  or  dried-out  patients, 
especially  when  fluid  can  not  he  readily  taken  through  the  mouth. 
In  my  experience,  this  solution  is  more  easily  absorbed,  less  ir- 
ritating, and  altogether  a  better  medium  to  decrease  nausea  and 
thirst,  than  saline.  The  tube  being  in  place,  allows  escape  of  gas, 
and  pains  due  to  Ibis  are  therefore  less  frequenl  where  this  measure 
is  employed.  The  catheter  causes  very  little  discomfort,  and  in 
many  cases  its  presence   is  not    known. 

Since  Kausch's'"  article  in  1911,  glucose  has  been  used  extensively 
in  surgical  cases.  It  not  only  supplies  energy  to  the  cells,  and  aids 
in  tissue  repair,  but  also  diminishes  acidosis  by  giving  carbohydrate 
food  to  the  organism.  It  therefore  greatly  aids  in  preventing  post- 
operative vomiting,  and  since  it  is  very  little  irritating,  if  ;it  all. 
to  the  mucous  membrane  of  the  bowel,  we  have  employed  it  as  a 
routine  in  our  plain  tap  water.  This  substance  is  burned  in  the 
body,  is  not  excreted  in  the  urine,  and  serves  as  a  food,  giving  300 
to  5()()  calories  per  day,  to  the  average  patient.  This  is  not  suffi- 
cient, however,  to  supply  the  total  energy  requirements  of  the  body. 


PROCTOCLYSIS  585 

but  greatly  aids  in  excessive  nitrogen  waste,  and  thus  we  get 
universally  good  results  from  its  use.  The  use  of  sodium  bicarbonate 
5  per  cent  in  the  fluid  given  per  rectum  decreases  the  tendency  to 
acidosis. 

Bibliography 

iMurphy:     Jour.  Am.  Med.  Assn.,  1909,  lii,  1248. 

sElbreeht :     Quoted  by  Murphy. 

sWechsler:     Jour.  Am.  Med.  Assn.,  1909,  lii,  1251. 

■iXeivmau:     Jour.  Am.  Med.  Assn.,  1909,  lii,  1250. 

sMcLean:     Jour.  Am.  Med.  Assn.,  1911,  lri,  1134. 

eSaxon:     Ann.   Surg.,   1909,  xlisr,  404. 

rBabler:     Jour.  Am.  Med.  Assn.,  1910,  liv,  870. 

sLawson:      Jour.  Am.   Med.  Assn.,  1908,  1,   1267. 

sDewitt:     Surg.  Gynec.  and  Obst.,  1911,  xii,  166. 
ioWeeks:      Jour.   Am.   Med.  Assn.,   1916,  lxxi.   1022. 
"Pharmacopoeia  of  the  United  States,  1916.  ix. 
i^Villmoth:     Am.  Jour.  Surg.,  1916,  xxx,  147. 
isEvans:      Jour.  Am.  Med.  Assn.,  1911,  rvii,  2126. 
"Brooks :     Arch.  Int.  Med.,  1910,  vi,  577. 
i-Campbell:     Jour.  Am.  Med.  Assn.,  1912,  lix,  1290. 
16Sippel:     Deutseh.  Med.  YVehnschr,  1910,  xxxvi,  Xo.  1. 
17 Joseph  and  Meltzer:     Jour.  Exper.  Pharm  and  Ther.,  1909. 
isTrout:     Surg.  Gvnee.  and  Obst.,  1913,  xvi,  562. 
is'Kausoh:     Deutseh.  med.  Wehnsehr.,  1911,  xxxii,  8. 
The  following  references  were  also  consulted: 
Burnham:      Am.  Jour.  Med.  Sc,  1915.  el,  435. 
Friedman:      Munehen.  med.  Wehnsehr.,  1913,  Lx,  1022. 
Kanavel :     Surg.  Gvnee.  and  Obst.,  October,  1916,  p.  485. 


.  CHAPTER  LVI 

HYPO l)ERMO(  LYSIS 
By  Willard  Bartlett,  St.  Louis,  Mo. 

Tt  will  be  readily  admitted  that  a  convalescenl  patient,  like  any 
other  human  being,  has  at  least  three  vital  necessities,  tie  can 
survive  but  a  very  limited  period  without  oxygen;  life  is  possible 
for  a  considerably  longer  time  without  water,  while  the  lack  of 
food  may  be  endured  for  quite  an  extended  term.  The  first  is.  of 
course,  a  vital  need;  the  second  becomes  one  in  a  relatively  short 
time,  while  the  third  will  ulti>n<t1<hi  assert  itself  in  much  the  same 
way.  The  first  and  third  have  been  dealt  villi  elsewhere,  and  this 
chapter  concerns  itself  with  what  I  believe  to  he  the  most  practical 
and  generally  useful  means  of  administering  water  to  an  individual 
who  can  not  take  it  in  the  normal  manner,  and  1  am  convinced 
that  very  many  patients  die  at  the  present  day  because  their  out- 
put exceeds  the  intake  which  is  possible,  in  the  physiologic  man- 
ner. 

There  is  the  greatesl  variety  of  conditions  in  which  the  swallow- 
ing of  water  and  its  absorption  in  the  lower  intestinal  tract  is  in- 
terfered with.  In  surgery  this  derangemenl  is  noted  mosl  com- 
monly following  the  action  id'  some  toxic  substance  like  an  anes- 
thetic, or  in  consequence  of  an  obstruction  in  the  digestive  tract, 
he  this  due  either  to  a  mechanical  or  to  an  inflammatory  cause. 
or  lastly,  in  individuals  where  we  dare  not  start  up  peristalsis  for 
the  damage  it  is  likely  jo  do  p<  >•  st . 

It  must  he  borne  ii*  mind,  as  a  fundamental  principle  underlying 
this  study,  that  water  is  not  absorbed  from  the  walls  of  the  stomach, 
or  indeed,  to  any  extent,  until  it  has  reached  the  colon:  hence, 
one  who  thinks  in  terms  of  physiology  readily  grasps  the  fact  that 
a  patient  who  is  vomiting  receives  no  fluid  into  his  circulatory 
apparatus,  and  therefore,  profits  not  a1  all  by  any  amount  that  is 
swallowed.  Unfortunately,  output  and  intake  are  not  a1  a  stand- 
still in  such  instances,  since  many  an  individual  who  vomits 
copiously,  really  ejects  more  than  he  drinks,  which  is  explained 
by  a  greatly  augmented  secretion  of  upper  intestinal  and  stomach 
juices.     As  dehydration    progresses,  such    patients   complain    more 

586 


HYPODERMOCLYSIS  587 

aud  more  of  an  agonizing  thirst,  no  matter  how  much  water  is 
swallowed. 

In  most  instances  where  water  can  not  be  taken  by  the  natural 
means,  it  is  injected  into  the  rectum,  and  although  it  may  surprise 
the  reader,  he  will  find  upon  investigation,  that  by  far  the  greater 
quantity  of  the  fluid  so  administered,  gradually  finds  its  way  into 
the  bedding  beneath  the  patient. 

Until  about  one  year  previous  to  the  time  this  is  written.  I,  like 
others,  in  the  habit  of  following  the  advice  of  well-known  leaders 
of  surgical  thought,  blindly  ordered  the  drop  by  drop  administra- 
tion of  water  per  anum.  with  great  frequency.  The  year-long  pro- 
tests of  patients  who  were  subjected  to  this  treatment,  finally  led 
me  to  take  up  the  matter  with  many  intelligent  nurses,  and  I  suc- 
ceeded in  eliciting  the  fact  that  a  very  small  percentage  of  fluid. 
which  is  intended  to  reach  the  circulatory  system  in  this  way.  ever 
really  accomplishes  this.  At  the  same  time,  practically  every  pa- 
tient is  disturbed  by  this  therapeutic  maneuver,  and  worst  of  all. 
active  peristalsis  is  started  up.  in  patients  suffering  from  peri- 
tonitis, just  that  type  in  which  the  intestines  should  remain  at  rest, 
and  fluid  be  rapidly  absorbed  instead  of  thrown  out  by  the  ac- 
tivated hollow  viscera. 

A  storm  of  protests  has  met  the  foregoing  arguments,  where 
presented  to  experienced  surgeons,  but  I  have  yet  to  find  that 
one  of  those  to  whom  I  have  mentioned  the  subject,  had  given  the 
matter  personal  attention,  and  still.  I  invite  any  man  who  is  really 
interested  in  it  to  remain  on  duty  with  the  nurse  for  an  hour  or 
two  after  the  administration  of  the  proctoclysis  which  he  has  or- 
dered. If  the  patient  remains  undisturbed,  and  the  fluid  be  definitely 
retained  in  any  satisfactory  percentage  of  the  patients  observed. 
I  think  he  had  better  continue  to  use  it. 

This,  however,  has  not  been  my  experience,  no  matter  what  the 
technic  employed:  and  I  may  adduce  as  the  best  proof  of  the  cor- 
rectness of  my  reasoning,  that  my  results  have  by  no  means  grown 
worse  during  the  year  that  it  has  not  been  employed  in  one  single 
instance. 

Another  way  of  introducing  water  into  the  circulatory  apparatus, 
when  swallowing  can  not  lie  allowed,  is  that  of  McArthur,  mentioned 
elsewhere  in  this  book,  who  lets  water  flow  into  the  gall  bladder 
through  the  drainage  tube  commonly  employed  in  that  viscus.  Mc- 
Arthur and  Matas  have  accomplished  wonders  in  this  way.  not  only 
in  the  administration  of  water,  but  of  fluid  nourishment  as  well. 
There  is  no  valid  objection  to  this  method  in  the  comparatively  rare 


588  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

instances  where  the  gal]  bladder  and  cystic  and  common  ducts  are 
available  for  this  purpose.  However,  it  will  be  readily  admitted 
that  a  comparatively  small  portion  of  our  surgical  work  is  done 
upon  1  he  biliary  apparatus. 

The  intravenous  infusion  of  salt  solution  or  other  physiologic 
fluids,  has  been  employed  with  success.  However,  this  is  a  dis- 
tinctly  dangerous  method  and  is  not  to  be  used  under  ordinary  cir- 
cumstances. I  can  nol  go  here  into  the  intricate  physiologic  rea- 
soning involved,  but  will  content  myself  with  mere  mention  of  the 
fact  Unit  every  surgeon  of  experience  lias  seen  a  terrific  chill,  with 
attendanl  depression,  follow  the  loo  rapid  inflow  of  salt  solution 
into  a  vein,  if  be  has  tried  to  introduce  a  reasonably  large  amount 
in  this  way.  Nothing  is  easier  to  produce  experimentally  than  an 
edema  of  the  lungs,  dilatation  of  .the  right  heart,  and  a  peritoneal 
accumulation  so  greal  as  to  interfere  with  the  excursions  of  the 
diaphragm,  by  the  overproduction  of  saline  into  a  vein.  It  goes 
then,  without  saying,  thai  the  method  has  obvious  disadvantages, 
and  is  not   to  be  employed  ;is  a  routine  procedure. 

The  intraperitoneal  introduction  of  fluid  is  quite  feasible,  but  is 
dangerous  unless  practiced  with  the  greatest  caution,  for  reasons 
that  are  apparent  to  any  one.  The  likelihood  of  injuring  an  ab- 
dominal viseus.  if  the  fluid  is  delivered  through  a  trocar,  is  always 
present.  One  m.us1  not  forgel  the  danger  of  interfering  seriously 
with  respiration  by  too  much  fluid  preventing  the  excursions  of  the 
diaphragm.  'This  method  is  employed  with  success  by  certain 
skilled  specialists  in  the  treatment  of  infantile  disorders.  How- 
ever, it  seems  quite  reasonable  to  suppose  that  it  can  never  occupy 
a  prominent  place  in  therapeutics,  if  it  has  to  be  used  as  a  routine 
procedure  by  physicians  at  large. 

After  having  condemned,  or  a1  least  urged  the  inadequacy  of 
the  last-mentioned  four  methods,  it  is  only  fair  that  I  should  pro- 
pose a  siil  ist  i  t  lit  o  for  them,  and  it  is.  indeed,  with  no  little  degree  of 
satisfaction  that  I  advocate  the  following  method  of  subcutaneous 
administration,  which  is  original  with  Dr.  McKittrick  and  myself, 
although,  il    must    lie  staled   in  all    fairness,  thai   after  we  had  used 

it  for  ( year.  Allen   P>.  Kauavel  of  Chicago,  who  knew  nothing  of 

our  work,  was  the  firsl  to  give  il  the  public  notice  it  deserved. 

The  apparatus  mosl  commonly  employed  by  us  consists  of  a 
graduated  sun  c.e.  glass  container  |  Pig.  ]!)]  i  which  is  connected  by 
rubber  tubing,  one-half  inch  in  diameter,  and  four  feet  long,  fo  a 
regular   hypodermic    needle   (No.    L8)    three   inches   long,   with    '.■■,■_. 


HYPODERMOCLYSIS 


589 


pig.    191. — The    drop    by    drop    hypodermic    introduction    of    water,    controlled    by    sight    feed. 

inch  bore.  When  continuous  hypo dermocly sis  is  used,  the  visible 
dropper  and  screw  clamp,  as  is  used  in  the  proctoclysis  outfit,  and 
also  a  clamp,  as  is  seen  ordinarily  with  regular  fountain  syringes, 
is  added. 


590 


AFTER-TREATMENT    OP    SURGICAL    PATIENTS 


An  attempt  is  made  to  gel  gravity  pressure  by  placing  the  con- 
tainer directly  above  the  patient.  This  maneuver  must  take  all  the 
kinks  out  of  the  tube,  and  thereby  encourage  the  proper  flow  of  the 
stream. 

As  to  the  fluid  employed.  Dr.  McKittrick  proposed  that  we  use 
plain,  freshly  distilled  sterile  water.  In  view  of  the  large  amounts 
of  fluid  instilled,  and  the  harmful  effects  which  occasionally  fol- 
low the  absorption  of  abnormal  amounts  of  sodium  chloride,  we  do 
not  countenance  its  use.  especially  in  patients  already  weakened 
liv  disease,  or  surgical   trauma.     The  water  is  heated  to  between 


Fig.    192. — The    needle    introduced    through    a    square    of    gauze. 


100°  to  11"  P.  and  then  poured  into  the  warm  container,  which 
is  supported  on  an  adjustable  pole.  The  slender  needle  is  first 
thrusl  through  the  center  of  a  square  fold  of  gauze  (Fig.  L92)  (25 
mesh  to  the  inch,  and  6  ply  thick),  and  is  now  ready  for  use.  This 
prevents  the  band  touching  the  needle  or  contaminating  the  skin, 
which  has  been  cleaned  with  alcohol,  and  painted  with  iodine  diluted 
';.,  its  strength  with  alcohol.  The  fluid  is  now  started  through  the 
tubing,  and  when  all  air  has  thereby  been  expelled,  the  tubing  is 
temporarily  pinched  off  with  the  thumb  and  finger,  and  the  opera- 
tion begins. 


HYPODERMOCLYSIS  591 

Iii  unconscious  patients,  the  needle  (Fig.  193)  is  plunged  up  to 
its  flange  in  the  subcutaneous  tissue,  at  a  point  near  the  outer  bor- 
der of  the  pectoral  muscles,  midway  between  the  nipple  and  the 
head  of  the  humerus.  By  this  method,  the  fluid  extends  directly 
into  the  subcutaneous  tissue  of  both  the  axilla  and  the  breast. 
Absorption  is  almost  twice  as  fast  as  it  is  when  the  injection  is 
under  the  breast  alone.  The  needle  is  held  in  place  by  a  strip  of 
adhesive,  (Fig.  193)  the  original  piece  of  gauze  being  utilized  to 
prevent  contamination  of  the  needle  wound.  If  the  needle  remains 
in  very  long,  alcohol  is  dropped  over  this  region  from  time  to  time, 


Fig.    193. — Needle    and    gauze    held    in    place    by    adhesive. 

and  gauze  is  then  placed  over  the  exposed  portion  of  the  needle, 
adhesive  and  all.  A  hot  water  bag,  wrapped  with  a  towel,  is  placed 
directly  under  the  axilla,  and  another  one  over  the  gauze,  which 
protects  the  needle.  Massage  is  not  attempted,  except  that  occa- 
sionally one  exerts  firm  rotary  pressure  over  some  slowhr  harden- 
ing area.  The  fluid  should  not  run  in  so  fast,  but  what,  with  the  aid  of 
the  hot  water  bottles,  the  tissues,  though  very  slightly  edematous, 
remain  soft  and  pliable.  Only  the  one  side  is  used  at  a  time  regard- 
less of  the  amount  of  fluid  to  be  infused.  Usually  1000  c.c.  is  given 
during  one  injection,  though  a  much  larger  amount  can  be  given 
if  it  is  allowed  to  run  in  slowly.    Between  one  and  two  hours  is  all 


592  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

the  time  needed  in  the  ordinary  ease,  and  frequently  one  hour  is 
sufficient,  tins  differing  with  individuals. 

Multiple  needles,  although  employed  by  some,  simply  add  to  the 
individual's  discomfort  by  multiplying  the  sources  of  it.  And  not 
only  this,  but  they  seem  to  me  to  violate  the  most  important  prin- 
ciple here  under  discussion,  viz..  that  they  may  deliver  the  fluid 
with  such  rapidity  as  to  incite  the  only  serious  danger  possible 
here,  that  of  circulatory  plethora,  followed  by  acute  dilatation  of 
the  right  heart,  and  first  made  evident  by  edema  of  the  lungs. 

In  giving  large  amounts  of  water,  the  heart  and  lungs  are  care- 
fully studied,  and  the  blood  pressure  taken  occasionally.  If  a 
dangerous  degree  of  plethora  is  produced  the  heart  heat  corre- 
spondingly increases  in  rate  and  force,  and  finally  the  heart  dilates. 
Then  the  blood  pressure  falls.  Other  less  ominous  signs  are  swell- 
ing of  the  eyelids,   face,  hands,   and   feet. 

The  giving  of  hypodermoclysis  is  easily  accomplished  without 
pain  or  distress  in  tnosl  patients  not  under  the  influence  of  a 
narcotic.  There  is  a  type  of  oversensitive  individual  in  whom 
more  than  this  is  necessary.  In  such  instances  a  very  fine  hypo- 
dermic needle  is  used  to  anesthetize  the  skin,  with  one-half  per  cent 
novocaine.  The  skin  is  then  punctured,  and  the  solution  carried 
along  the  route  which  the  hypodermoclysis  needle  will  follow. 
This  is  inserted  as  soon  as  the  patient  is  unable  to  feel  any  pain. 
The  clamp  is  now  gradually  released,  so  as  to  permil  the  water  to 
enter  slowly,  and  diffuse  the  anesthetic  ahead  of  it.  After  a  few 
minutes  the  patient  will  experience  a  little  pain  from  the  pressure 
of  the  water.  The  tube  is  then  clamped  off.  and  a  small  quantity 
of  y2  per  cenl  oovocaine  injected  into  it  under  pressure,  by  means 
of  a  10  c.c.  syringe  i  Pig.  194).  The  pain  having  ceased,  the  water 
is  again  turned  on.  and  the  patient  can  take  a  few  hundred  more 
c.c.  when  furl  her  injection  of  novocaine  may  fie  made.  If  more 
than  one  reservoir  full  is  required,  more  water  is  poured  into  the 
reservoir  and  the  injection  of  novocaine  repeated  as  often  as  the 
patienl  complains  of  pain.  This  will  not  occur  more  than  once  or 
twice  during  the  hour. 

In  patients  who  may  lie  relied  upon  to  let  the  needle  alone 
continuous  hypodermoclysis  may  fie  employed.  In  ihis  case,  by 
means  of  a  dropper  and  screw  clamp,  the  water  is  given  in  drops. 
while  the  rate  of  flow  varies  with  the  rate  of  absorption.  The  tis- 
sues are  not  allowed  to  become  swollen.  The  patient  will  usually 
take  40  to  80  drops  to  the  minute  withoul  this  occurring.  Such  a 
method    is   indeed   desirable,   one   which    permits   fluid   to   enter  the 


HYPODERMOCLYSIS 


593 


tissues  to  the  extent  that  pain  is  caused.  If  this  occurs,  the  patient, 
(if  he  is  one  to  be  trusted)  may  stop  the  flow  by  means  of  an 
ordinary  syringe  clamp,  supplied  for  this  purpose,  and  when  the 


Fig.    194. — A.      A   hot-water   bottle   in   position.     B.      Novocaine    introduced   repeatedly    during 

the   operation. 


pain  ceases,  he  can  start  the  solution  by  releasing  his  clamp.  "When 
the  hypodermoclysis  operation  is  finished,  the  needle  wound  is 
cleansed  with  alcohol,  and  then  closed  by  means  of  adhesive  or  a 


,'.)- 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


little  cotton  and  collodion.  Heat  is  continuously  applied  until  all 
traces  of  the  fluid  have  disappeared,  and  the  soreness  gone. 

We  have  given  fluid  by  this  method  for  a  period  of  several  days. 
In  one  case,  McKittrick  gave  10,000  e.c.  in  less  than  three  days: 
on  numerous  other  occasions,  we  have  employed  large  amounts 
with  good  results. 

We  have  never  seen  a  patient  show  evidences  of  having  received 
too  much  fluid,  nor  incurred  any  harmful  results  from  the  use  of  this 
method;  we  have  on  the  other  hand  observed  time  and  again,  pa- 
tients who  seemed  in  the  utmost  extremity  of  dehydration  com- 
patible with  life,  make  a  most  satisfactory  convalescence  when  it 
was  used. 


Fig.    195. 


Fig.    196. 


Figs.    1  An    apparatus    for   maintaining   the   temperature    of   a    fluid    to    In-    intro- 

duced   under    the    skin,    used    at     Mayo    Clinic. 


McKittrick,  as  far  as  the  writer  knows,  is  the  pioneer  in  the 
use  of  plain  distilled  sterile  water  in  continuous  hypodermoelysis. 
Kanavel  used  the  continuous  method,  bu1  physiologic  saline  solu- 
tion was  introduced  instead.  We  have  seen  no  ill  effects  from  the 
water  infusions,  cither  in  the  skin  or  subcutaneous  tissues,  and  the 
absorption  seemed  much  quicker  than  wilh  the  saline  solution. 
In  testing  out   this   point,    McKittrick    injected   1600   e.c.   of   plain 


HYPODERMOCLYSIS  595 

water  into  one  axilla  of  a  patient,  and  saline  into  the  other  at  the 
same  time.  The  plain  water  disappeared  from  the  reservoir  thirty 
minutes  to  one  hour  the  sooner,  and  the  tissues  next  day  were 
normal,  so  far  as  physical  examination  was  possible,  while  those 
in  which  the  salt  solution  was  injected,  were  the  seat  of  soreness, 
and  considerable  crepitus  was  present. 

As  is  perfectly  well  known  to  physicians,  the  blood  pressure  can 
not  be  raised  above  normal  by  the  infusion  of  fluid  into  the  veins, 
no  matter  what  quantity  be  employed.  Any  attempt  in  this  direc- 
tion simply  causes  extravasation. 

McKittrick  believes  on  the  other  hand,  that  the  subcutaneous 
infusion  of  distilled  water  has  lowered  unnecessarily  high  blood 
pressures  in  the  cases  of  which  he  has  kept  blood  pressure  records. 
He  goes  so  far  as  to  conclude  that  he  has  seen  unduly  high  arterial 
tension  in  chronic  interstitial  nephritis  rendered  lower  in  this  man- 
ner. 

We  must  state  in  conclusion,  that  the  procedure  has  completely 
supplanted  the  rectal  administration  in  my  service,  and  where  in- 
telligently applied,  seems  not  to  have  unduly  disturbed  the  patient. 
has  never  been  attended  by  an  accident,  and  has  given  the  greatest 
satisfaction. 


CHAPTER  LVII 

BLOOD  TRANSFUSION 
By  Willard  Bartlett,  St.  Louis,  Mo. 

We  can  imagine  no  more  striking  introduction  to  this  subject 
than  the  words  of  McClure  and  Dunn,1  which  Ave  present  verbatim: 

"From  the  very  earliest  times,  the  blood  has  been  regarded  as 
synonymous  with  life.  It  was  considered  by  the  ancients  as  the 
sea)  of  the  soul.  In  the  Bible  we  have  the  following:  'Because 
the  life  of  the  flesh  is  in  the  blood  and  I  have  given  it  to  you  upon 
the  altar  to  make  an  atonement  for  your  souls:  for  it  is  the  blood 
that  maketh  an  atonement  for  the  soul.'  Many  references  are  made 
to  transfusion  of  blood  in  the  writings  of  the  ancient  Egyptians. 
It,  was  condemned  by  Pliny  and  Celsus.  Tn  the  Metamorphoses  of 
Ovid  we  have:  'Quid  nunc  dubitatis  inertes?  Stringite,  ait,  gladios; 
veteremque  haurite  cruorem,  ut  repleam  vacuus  juvenili  sanguine 
vi  ikis.'  'Why,  now.  do  ye  hesitate  and  do  nothing?  Unsheathe  your 
swords  and  draw  out  the  old  blood,  that  I  may  fill  the  empty  veins 
with  the  blood  of  the  youth.'  Libavius  in  1615  reports  in  eDe- 
fensione  Syntagmatis  arcanorum  chymicorum'  as  follows:  'Let  there 
be  present  a  robust,  healthy  youth  full  of  lively  blood.  Let  there 
come  one  exhausted  in  strength,  weak,  enervated,  scarcely  breath- 
ing. Let  the  master  of  the  art  (the  operator)  have  silver  tubes 
that  can  be  adapted  one  to  the  other;  then  let  him  open  an  artery 
of  the  healthy  one,  insert  the  tube,  and  secure  it.  Next  let  him 
incise  the  artery  of  the  patient  and  put  into  it  the  feminine  (re- 
ceiving) tube.  Now  let  him  adapt  the  two  tubes  to  each  other 
and  the  arterial  Mood  of  the  healthy  one,  warm  and  full  of  spirit, 
will  leap  into  the  (vessels  of  Hie)  sick  one,  and  immediately  will 
bring  to  him  the  fountain  of  life  and  will  drive  away  all  languor.'  ' 

However,  the  first  authentic  record-  we  have  is  that  of  Pope  In- 
nocent VIII,  who  was  transfused  by  his  Jewish  physician  in  L492. 
three  little  boys  being  used  as  donors;  this  doctor,  whose  name  has 
been  lost  to  science,  failed  to  benefit  his  patient.  No  other  attempts 
were  made  to  perfect  the  procedure  further  than  discussion  of  it, 
until  Harvey's  discovery  of  the  circulation,  when  new  interest  was 
manifested  and  research  work  was  done  upon  animals,  but  it  was 
not   before  the  middle  of  the   17th  century  that    it    was   recognized 

596 


BLOOD    TRANSFUSION  597 

as  a  surgical  procedure.2  During  the  year  1666,  in  France,  Lower 
first  gave  a  method  in  detail,  and  Denny's  experimenting  along  the 
same  lines,  successfully  transfused  three  human  beings.  Following 
their  work,  many  instances  of  transfusion  were  reported,  sometimes 
from  animal  to  man,  and  at  times  from  man  to  man.  The  vessels 
were  connected  end  to  end  or  by  means  of  a  quill  or  cannula  of  silver 
or  of  bone,  or  indirectly  by  a  pump  or  syringe.  Several  successful 
attempts  were  reported,  but  such  fierce  opposition  was  aroused  that 
in  1668,  the  method  was  forbidden  except  by  special  permit  of  the 
Faculte  of  Paris.3 

This  naturally  had  a  disquieting  effect,  and  except  for  a  dis- 
cussion now  and  then,  the  method  fell  into  disuse  and  was  not  re- 
vived until  the  19th  century.  At  this  time,  Blundell4  in  England 
did  further  experimental  work  helping  to  more  firmly  establish 
this  procedure  as  an  important  step  in  experimental  physiology. 
Work  continued  uninterruptedly,  and  by  the  middle  of  the  century 
(1863),  Blasius  had  collected  116  cases  of  transfusion,  performed 
during  the  preceding  forty  years,  and  found*  56  successful  results. 
In  two  cases  alone,  the  serum  was  from  animals,  and  in  all  cases  the 
indirect  method  was  used. 

Men  became  highly  enthusiastic,  great  claims  were  advanced  for 
transfusion  and  many  operative  methods  were  devised,  but  it  soon 
became  apparent  that  these  claims  were  unfounded  after  Landois 
discovered  that  heterogeneous  blood  could  not  be  used  because  of 
red  blood  corpuscular  destruction,  and  Blasius'  defibrinated  blood 
was  found  dangerous  because  its  fibrin  ferment  caused  coagulation. 
The  general  introduction  of  normal  salt  solution,  about  1875,  brought 
about  a  gradual  decline  in  the  transfusion  of  blood  until  1880,  when 
it  was  again  revived  and  followed  with  vigor  until  today. 

I  had  the  good  fortune  recently,  to  learn  through  personal  com- 
munication, the  details  of  the  first  transfusions  done  in  America 
by  Dr.  W.  S.  Halsted.  He  had  several  patients  suffering  from 
carbon  monoxide  poisoning,  whom  he  treated  by  withdrawing 
blood,  defibrinating  the  same  and  re-fusing  it  into  the  same  indi- 
vidual. These  were  all  arterial  in  nature,  the  blood  being  returned 
in  the  centripetal  direction. 

We  shall  now  turn  from  the  historical  aspect  of  our  subject,  in 
an  effort  to  study  the  individual  who  is  best  suited  to  act  as  a 
donor.  It  is  of  such  importance  to  select  the  right  person  that  in 
our  largest  clinics  these  people  are  hired  and  kept  ready  to  meet 
any  emergency.5  A  Wassermann  reaction  must  be  made  on  them, 
as  in  the  case  of  every  other  donor. 


598  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

Lewisohn  reminds  us  that  "the  following  important  facts  ought 
to  be  kept  in  mind  in  connection  with  this  question:  1.  Donors  can 
not  he  used  a  second  time  for  the  same  patient  without  another 
test  as  to  hemolysis  and  agglutination.  2.  Blood  relatives  (parents 
and  children,  brothers,  etc.)  have  to  be  tested  just  as  thoroughly 
as  strangers,  as  their  blood  often  is  very  incompatible  in  spite  of 
their  near  blood  relationship.  Cherry  and  Langrock  have  asserted 
that  in  newborn  infants  the  mother's  blood  can  always  be  used 
with  perfect  safety  for  a  transfusion.  Other  workers,  however, 
do  not  agree  with  this  statement." 

These  donors  are  selected  by  the  method  of  Moss.1  which  is  based 
on  the  principle  that  before  the  serum  of  one  blood  will  cause  an 
hemolysis  of  the  corpuscles  of  another,  it  will  first  or  simultaneously 
cause  an  agglutination  of  the  corpuscles.  The  reverse,  that  all  eases 
which  show  agglutination  will  also  show  hemolysis,  is  not  neces- 
sarily true,  occurring  in  only  about  20  per  cent  of  cases.  Adopting 
this  principle,  all  bloods  are  classified  according  to  the  agglutina- 
tive properties  of  their  elements,  into  one  of  four  groups.  In  se- 
lecting the  donor  then,  it  is  advisable  to  have  one  whose  blood 
belongs  to  The  same  group  as  that  of  the  patient.  If  this  is  im- 
possible, the  donor's  blood  should  belong  to  a  group  whose  corpus- 
cles are  not  agglutinated  by  the  serum  of  the  patient. 

Group  I. — Serum  does  not  agglutinate  corpuscles  of  any  group. 
Its  corpuscles  are  agglutinated  by  serum  of  11.  Ill  and  IV. 

Group  II. — Serum  agglutinates  corpuscles  of  (iroups  I  and  II.  but 
not  IV.  Corpuscles  are  agglutinated  by  serum  of  Groups  111  and 
IV.  but  not  I. 

Group  III. — Serum  agglutinates  corpuscles  of  Groups  I  and  II.  but 
not  IV.  Corpuscles  agglutinated  by  serum  of  (iroups  II  and  IV. 
but  not  I. 

Group  IV.  Serum  agglutinates  corpuscles  of  (iroups  I.  II.  and  III. 
Corpuscles  are  not  agglutinated  by  any  serum. 

Seven  per  cent  of  all  donors  belong  to  Group  I;  40  per  cent  to 
Group  II;  10  per  cent  to  Group  III  :  and  4:1  per  cent  to  Group  IV. 

The  serum  of  one  group  will  not  agglutinate  the  corpuscles  of 
blood  belonging  to  the  same  group. 

In  grouping  the  bloods,  the  unknown  blood  should  be  tested  with 
a  blood  whose  group  is  known.  This  "standard"  blood  must  be- 
Long  to  either  (iron])  II  or  III  in  order  to  be  of  value  in  grouping 
oilier  blood.  The  group  to  which  a  blood  belongs  remains  constant. 
It  is  in >1  influenced  by  age,  disease  or  transfusion  of  blood  belonging 
to  another  group. 


BLOOD    TRANSFUSION  599 

Technic. — A  puncture  wound  is  made  in  the  finger  and  eight  to 
ten  drops  of  blood  are  allowed  to  flow  into  a  small,  clean,  dry  test 
tube.  From  five  to  eight  drops  are  allowed  to  flow  into  a  second 
tube  that  contains  2  to  3  c.c.  of  V/2  per  cent  sodium  citrate  solution. 
These  tubes  are  centrifuged  for  five  minutes.  The  fibrin  and  blood 
cells  in  the  first  tube  will  have  clotted  and  settled  to  the  bottom, 
allowing  the  clear  serum  to  remain  on  top.  The  corpuscles  of  the 
second  tube  will  have  settled  at  the  bottom.  The  supernatant  fluid 
in  this  tube  is  carefully  withdrawn  and  2  to  3  c.c.  salt  solution  are 
added  to  the  corpuscles  to  wash  them.  This  tube  is  again  centri- 
fuged for  3-5  minutes.  The  supernatant  fluid  is  withdrawn  by  a 
pipette  and  a  5  per  cent  suspension  of  the  corpuscles  in  normal  salt 
solution  is  made.  The  standard  blood  of  the  known  group  is  pre- 
pared in  the  same  manner.  Then  using  a  platinum  loop,  a  loopful 
of  the  5  per  cent  suspension  of  corpuscles  from  the  blood  to  be 
grouped,  (blood  A)  is  placed  on  a  clean  cover-glass.  Two  loopfuls 
of  serum  of  the  standard  of  known  blood  (B)  are  placed  on  the 
same  cover-glass.  To  prevent  a  possible  masking  of  agglutination 
by  an  accompanying  hemolysis  which  occasionally  takes  place,  a 
loopful  of  serum  of  blood  A  is  also  placed  on  the  cover-glass  and 
all  carefully  mixed,  and  the  cover-glass  is  placed  on  a  hanging 
glass  slide.  If  there  is  to  be  any  agglutination,  the  clumping  of  the 
cells  can  be  seen  under  the  microscope  in  from  one  to  three  minutes. 
Macroscopic-ally,  if  there  is  agglutination,  a  brick-dust  sediment 
will  be  seen  in  the  drop.  A  second  drop  is  made  by  using  one  loop- 
ful of  5  per  cent  suspension  of  corpuscles  from  blood  B.  one  loop- 
ful of  serum  B,  and  two  loopfuls  of  serum  of  blood  A.  The  results 
of  these  drops  are  noted  and  then  compared  with  the  chart  of 
groups. 

By  using  this  method,  blood  can  be  grouped  in  from  30  to  40 
minutes,  and  after  a  patient  is  once  grouped,  he  does  not  have  to 
be  subsecfuently  inconvenienced  by  having  his  blood  reexamined 
if  a  second  donor  is  to  be  used. 

Minot7  states  that  hemolysis  will  not  occur  always  even  if  the 
donor  and  recipient  do  not  belong  to  the  same  iso-agglutination 
group,  since  only  20  per  cent  of  sera  that  are  agglutinate  are 
hemolytic.    Hemolysis  never  occurs  without  agglutination. 

Lindemans  has  found  that  the  preliminary  blood  tests  for  hemoly- 
sis and  agglutination  as  done  by  various  serologists  do  not  always 
agree,  and  therefore  are  not  reliable,  so  he  examines  the  blood  him- 
self, the  technic  being  as  follows:  The  red  blood  cells  of  the  pa- 
tient and  donor  are  washed  three  times  with  normal  saline ;   va- 


600  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

riable  quantities  of  patient  V  serum  are  placed  in  three  separate 
small  test  tubes;  to  each  of  these  is  added  0.25  e.e.  of  a  2  per  cent 
suspension  of  washed  blood  cells  of  the  donor.  The  same  is  done 
with  the  donor's  serum  and  the  patient's  eells.  Controls  are  made 
of  donor's  serum  and  donor's  eells.  patient's  serum  and  patient's 
cells.  Controls  arc  also  made  with  donor's  eells  in  normal  salt 
solution  and  patient's  eells  in  normal  salt  solution.  The  total 
volume  in  each  tube  is  raised  with  normal  saline  to  0.5  c.c.  of 
volume.  The  test  tubes  are  incubated  in  a  water-bath  for  a  period 
of  two  hours,  and  readings  are  made.  They  are  then  set  into  the 
ice  box  overnight  and  readings  arc  again  taken  the  following  morn- 
ing.   When  a  case  i-  urgent,  the  ice  box  test  is  eliminated. 

Since  Lindeman  has  applied  his  technic  of  testing  donors,  his  last 
155  transfusions  by  the  syringe  cannula  system  have  been  per- 
formed without  the  loss  of  a  single  case  hy  death.  Chills  followed 
by  a  rise  in  temperature  occurred  in  16  instances.  He  has  found 
that  hemolysis  never  occurs  without  chills  and  fever  unless  the  pa- 
tient dies  during  or  shortly  after  the  transfusion,  lie  infers  there- 
fore that  chills  and  fever  in  transfusion  are  due  to  hemoglobin 
set  free  in  the  circulating  Mood.  If  the  hemoglobin  set  free  "s 
abundant,  it  appears  in  the  urine;  when  the  amount  is  moderate 
hematoporphyriu  appears  in  the  urine.  It  would  appear  to  him  that 
four  conclusions  as  to  ineompatability  are  warranted. 

1.  The  preliminary  hemolytic  and  agglutination  tests  when 
properly  performed  are  reliable. 

2.  Incid  hemolysis  in  transfusion  can  be  eliminated  en- 
tirely. 

3.  The  reactions  which  follow  transfusion  when  accurate  tests 
have  been  made  are  eliminated  in  all  except  0  per 

In  this  0  per  cent,  chills  and  :'•  :eur.    When  the  quantity 

is  800  c.c.  or  less,  chills  and  fever  do  not  occur. 

4.  By  careful,  accurate,  and  complete  hemolysis  and  agglutinin 
tests  s  anted  that  work  is  done  skillfully,  blood  transfusion  is 
robbed  of  all  danger  attending  its  use. 

Ottenberg  and  Kaliski  estimated  that  there  are  toxic  reactions, 
nut   referable  to  agglutination  or  hemolysis,  in  10  per  cent  of  all 
-.  as  based  on  their  own  series  "i  128  cases. 

<  >ttenberg  and  Libman  in  their  series  of  212  eases  of  transfusions, 
in  summarizing  the  untoward  results  due  to  transfusions,  assign 
the  most  unfavorable  reactions  of  their  scries,  including  5  deaths, 

to  "incompatible  hi 1"    meaning  hemolj  «  'glutinatiou  only 

or  to  hypertransfusion.     They  stal  appeared  in  1<>  per  cehl 


BLOOD    TRANSFUSION  601 

of  all  cases,  skin  eruptions,  usually  urticarial,  occasionally  petechial, 
appeared  in  another  10  per  cent.  In  referring  to  the  hemolytic 
and  agglutination  reactions  as  being  an  insufficient  guide  to  the 
value  of  a  given  donor's  blood  for  the  purpose  of  stimulating  a 
remission  of  the  disease  in  pernicious  anemia,  they  make  the  state- 
ment that  "there  are  probably  other  not  yet  recognized  dif- 
ferences between  the  bloods  of  donors." 

Lewisohn10  reports  5  febrile  reactions  and  3  chills  in  22  trans- 
fusions. 

Two  cases  with  favorable  agglutination  and  hemolysis  tests,  in 
which  there  were  toxic  reactions,  are  reported  by  Cooke  in  a  series 
of  12  transfusions. 

Those  with  experience  in  blood  transfusions  have  observed  cer- 
tain toxic  symptoms  varying  all  the  way  from  a  slight  chill  and  rise 
in  temperature  to  marked  anaphylactoid  phenomena,  and  even 
death  has  occasionally  resulted  as  the  immediate  sequela  to  trans- 
fusion even  where  the  serologic  tests  for  hemolysis  and  agglutina- 
tion have  been  entirely  favorable.  To  explain  this  the  three  fol- 
lowing hypotheses  have  been  suggested  by  Pemberton : 

1.  It  is  possible  that  trypsin-antitrypsin  balance  in  the  circulat- 
ing blood  of  the  recipient  may  be  so  disturbed  by  the  commingling 
with  the  donor's  blood  as  to  result  in  the  immediate  formation  of 
serotoxin  from  cleavage  of  serum  protein. 

2.  It  is  possible  that  the  action  of  the  protective  colloids  in  the 
body  cells  of  the  recipient  may  be  so  disturbed  that  these  cells  are 
thereby  exposed  to  a  reaction  of  antigen  and  antibody  present  in 
the  circulation  of  the  recipient  but  harmless  to  the  protected  cell. 

3'.  There  is  the  possibility  of  a  toxic  disturbance  in  the  circula- 
tion of  the  recipient  by  the  introduction  of  blood  which,  though  per- 
fectly fluid,  may  nevertheless  be  undergoing  incipient  coagulative 
changes  due  to  physical  influences  to  which  it  is  subjected  in  proc- 
ess of  transfer. 

Now,  having  read  the  laboratory  side  of  this  important  border- 
line subject,  let  us  note  the  opinions  of  three  experienced  surgeons 
on  it. 

Deaver11  claims  that  too  much  mystery  has  surrounded  blood 
transfusion  and  that  most  of  the  instruments  for  its  performance 
are  too  complicated,  and  therefore  can  be  of  little  use  to  the  sur- 
geon. He  points  out  that  in  25  per  cent  of  all  cases  transfused,  hemoly- 
sis occurs.  Too  much  attention  can  not  be  given  the  donors.  The 
methods  of  Crile,  Brewer,  McGrath  and  others  are  criticized  be- 


602 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


cause  amount  of  blood  transfused  can  not  be  measured,  and  while 
Beaver  does  not  believe  it  necessary  to  be  absolutely  exact,  he 
thinks  it  is  best  to  keep  within  the  limits  of  safety,  for  some  cases 
require  only  small  amounts.  He  employs  the  spurt  method  to  de- 
termine the  amount  of  blood  used,  the  radial  artery  being  selected 
because  of  the  driving  force  of  the  heart.  The  blood  is  allowed  to 
spurt  into  a  small  graduate;  if  it  takes  5  spurts  to  reach  the  dram 
mark,  each  spurt  will  contain  12  drops,  and  a  pulse  of  80  will  there- 
fore discharge  2  ounces  in  one  minute.  This  is  considered  as  ac- 
curate as  il   is  simple. 


7.  —  Instruments  and   material   used    in   direct    M 1   transfusion. 


The  authors  have  had  no  experience  with  this  and  therefore  do 
not  endorse  it,  as  interesting  as  it  sounds. 

Percy12  finds  that  the  tests  for  hemolysis  and  agglutination  in 
vitro  as  described  by  Rons  and  Turner,  arc  not  dependable,  and 
he  gives  a  preliminary  transfusion  of  20  c.c.  of  blood  intravenously 
by  hypodermic  syringe,  believing  that  this  amount  of  blood  will  in- 
dicate hemolytic  phenomena  without  serious  sequelae,  or  the  full 
expression  of  the  cardinal  signs  of  fatal  hemolysis  which  are: 
vomiting,  respiratory  distress,  pain  low  in  the  back,  a  characteristic 
flush  and  profuse  sweating  followed  by  pronounced  chills  and  sup- 
pression of  urine. 


BLOOD    TRANSFUSION 


603 


Blood  transfusion  is  in  reality  a  homologous  transplant  of  liv- 
ing tissue,  the  tissue  being  a  complex  fluid  which  possesses  the 
ability  to  coagulate  under  certain  conditions.13  According  to  Hart- 
well,  who  bases  his  opinion  upon  a  study  of  the  recent  literature, 
a  small  dose  may  produce  the  same  effect  as  a  massive  one  by 
chemical  reaction.  The  only  condition  in  which  a  massive  trans- 
fusion of  whole  blood  seems  indicated  is  after  a .  loss,  from  direct 
hemorrhage,  of  such  severity  that  life  is  endangered  because  of  in- 
sufficient blood  to  maintain  oxygenation.  There  can  be  no  argument 
against   blood  transfusion,   properly  performed,   in   cases   of   acute 


Fig.    198. — Dissecting  out  the  vein. 


hemorrhage,  the  object  being  to  replace  the  blood  which  is  lost. 
The  red  cells,  while  quickly  destroyed,  serve  as  oxygen  carriers 
and  may  tide  over  an  emergency  until  the  bone  marrow  can  re- 
place the  lost  cells. 

The  indications  for  blood  transfusion  in  addition  to  the  above 
are  as  follows  :14 

1.  Marked  secondary  anemias,  either  as  a  palliative,  or  as  a 
preoperative  measure. 


604 


after-treatment  of  surgical  patients 


2.  Essential  anemias. 

3.  Blood  dyscrasias,  if  fresh  human  serum23  injections  or  throm- 
bin are  ineffective. 

4.  Disorders  in   the   process   of   coagulation   with   increased   sus- 
ceptibility to  hemorrhage. 

5.  Deficiency    of    the   respiratory    elements    sufficient    in    degree 
to  impair  the  integrity  of  vital  organs. 

6.  Chronic   localized   infections   of   known   etiology   amenable   to 
treatment,  immunized  blood  should  be  used  in  such  case-. 

The  ideal  technic  for  transfusion  involves  four  factors:  absolute 


99.- — riacing    the    waxed    black    silk    cloth    under    thi 


asepsis;  no  blood  change;  ability  to  measure  the  quantity  trans- 
fused: and  ease  of  accomplishment  for  donor,  recipient  and  operator. 
Of  the  three  met  hods  in  vogue,  the  direct  intima  to  intima  suture 
method,  popularized  by  Carrell,  and  the  intima  to  intima  cannula 
method  of  Payr.  Sweel  and  Crile  (Figs.  L97  to  204  .  are  difficult 
procedures  and  no  measure  of  the  amount  transfused  can  be  re- 
corded. The  second  direct  method,  the  employment  of  a  paraffin- 
coated  tube  as  a  connecting  link  between  donor  and  recipient,  is 
also  far  from  ideal,  as  no  quantitative  estimation  is  possible  and  the 
danger  of  clotting   is  always  present.     In   both   of  these,   the    re- 


BLOOD    TRANSFUSION 


605 


eipient  may  infect  the  donor,  while  there  is  a  real  psychic  clanger 
to  both  individuals  as  a  result  of  coupling  them  together. 

The  third  and  best  method  is  an  indirect  one  employing  an  in- 
termediate receptacle,  either  making  the  transfer  so  rapidly  that 
the  blood  has  been  drawn  and  discharged  into  the  recipient's  vein 
in  less  than  normal  coagulation  time,  or  by  the  simpler  plan  of 
adopting  means  to  delay  or  prevent  coagulation. 

The  indirect  methods  possessing  a  clinical  value  are  of  three  gen- 
eral forms:  (1)  Those  employing  syringes.  (2)  Those  employing 
anticoagulates.  (3)  And  those  employing  receptacles  of  which  the 
Kimpton-Brown  serves  as  a  type. 


Pig.    200. — Placing   bull   dog  clamps  and   oiling  vein  with   a   lubricant. 


A  good  syringe  •  method  was  described  by  Lindeman,15  whose 
technic  is  as  follows :  Specially  devised  cannulas  are  painlessly  in- 
serted into  the  veins  of  the  donor  and  patient  without  the  skin 
incision  if  possible.  About  15  syringes  are  used.  No  syringe  is 
used  a  second  time  until  thoroughly  cleaned.  One  operator  manages 
the  syringe  of  the  donor  and  another  that  of  the  patient.  One 
syringe  is  being  filled  while  the  other  is  emptied.  A  little  salt  solu- 
tion is  allowed  to  trickle  through  the  cannulas  every  now  and  then 
to  prevent  the  possibility  of  any  coagulation  in  them.  It  requires 
from  six  to  twelve  seconds  to  fill  and  empty  a  syringe.    The  largest 


606 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


quantity  of  blood  be  has  taken  from  one  donor  in  one  sitting  is 
1500  c.c.:  the  time  required  was  fifteen  minutes;  30  e.e.  salt  solution 
was  used.  Since  the  coagulation  time  of  blood  drawn  into  a 
syringe  is  never  less  than  five  minutes,  and  in  this  method  the  blood 
is  no  longer  in  the  syringe  than  twelve  seconds,  coagulation  is 
almost  out  of  the  question.  Adults  received  from  1000  to  1800  c.c. 
in  each  transfusion,  and  the  quantity  stated  was  always  taken 
from  one  donor.  Xo  foreign  substance  or  anticoagulant  was  em- 
ployed in  any  case.    By  this  technic  the  entire  mass  of  blood  is  out- 


Fis 


-Win    cut    in    ■  ,  I    put    through    at    one    end,    hemostat    al 

out  vein  with  saline. 


Washing 


side  the  body  only  for  a  period  of  from  six  to  twelve  seconds,  re- 
gardless of  tin-  amount  transferred.  It  passes  through  a  minimum 
amount  of  foreign  material. 

Miller16,  in  the  hope  of  finding  a  method  of  performing  blood 
transfusion  which  would  overcome  all  objections  to  the  multiple 
syringe  method  of  Lindeman,  devised  a  valve,  which  consists  of  a 
central  body,  a  cylinder  1.5  inches  long  and  0.5  inches  in  diameter, 
with  two  arms  extending  in  opposite  directions.  From  the  middle 
of  the  central  body  projects  a  cylindrical  stem  jusl   large  enough 


BLOOD    TRANSFUSION 


607 


Fig.    202. — Drawing   donor's   vein    through    cannula. 


Fig.    203. — Vein   drawn   back   and   tied   at   second   notch   on    cannula.      Oil    dropped    into   vein 
to  prevent  drying  of  surface. 


608 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


to  receive  the  tip  of  a  record  syringe.  The  two  arms  are  connected  to 
pieces  of  12F.  rubber  tubing,  three  inches  long.  In  the  distal  end 
of  each  tube  a  metal  tube  is  inserted,  which  fits  two  cannulas  and 
needles  used  for  donor  and  recipient.  By  moving  a  thumbscrew 
back  and  forth,  the  current  can  be  directed  into  either  arm.  By 
withdrawing  the  piston,  the  syringe  is  filled  with  blood,  the  thumb- 
screw is  changed  toward  the  recipient's  arm  and  the  syringe  emp- 
tied rapidly.  The  operator  continues  to  alternate  the  direction  of 
the  thumbscrew,  filling  and  emptying  the  syringe,  without  discon- 
necting it  from  the  valve,  until  the  desired  amount  of  blood  lias 
been  transfused. 


Placing    and    tying    recipient's    vein    over    cannula. 


Lewisohn's10  work  was  begun  with  the  idea  of  simplifying  the 
technic  of  blood  transfusion.  The  objed  of  this  work  was  to  find  an 
atoxic  anticoagulant  which  would  prevenl  the  blood  from  clotting 
during  the  transfer  from  donor  to  recipient. 

From  a  series  of  animal  experiments  the  following  facts  were 
elucidated : 

1.  Sodium  citrate  mixed  with  blood  in  the  ratio  of  0.2  per  rent 
will  prevenl  the  blood  from  (dotting  for  two  to  three  days. 

2.  The  coagulation  time  of  the  recipient's  blood  tested  after  tlie 


BLOOD    TRANSFUSION  609 

transfusion  of  citrated  blood,  is  shortened,  but  after  a  few  hours 
the  coagulation  time  again  becomes  normal. 

3.  Sodium  citrate  is  only  conditionally  atoxic.  Animal  experi- 
ments show  that  if  1  per  cent  instead  of  0.2  per  cent  citrate  is 
present  in  the  blood,  transfusions  of  large  amounts  of  citrated  blood 
are  fatal. 

The  author  gives  detailed  reports  of  22  blood  transfusions  per- 
formed by  this  method.  The  largest  amount  transfused  at  one  time 
was  1000  c.c.  In  one  case,  1600  c.c.  were  given  to  a  patient  within 
24  hours.  Xo  untoward  symptoms  occurred  in  any  of  the  cases. 
Some  showed  a  moderate  polyuria,  caused  by  the  introduction  of 
the  citrate.  There  were  no  macroscopic  or  microscopic  changes  in 
the  urine. 

Hemoglobin  tests  taken  a  few  days  after  the  transfusion  show 
that  the  citrated  blood  is  clinically  as  valuable  as  unmixed  blood. 
Even  hemorrhagic  conditions  are  no  contraindication  against  the 
use  of  this  method,  as  the  coagulation  time  of  the  recipient's  blood 
is  shortened  after  the  transfusion  of  citrated  blood. 

The  new  method  offers  the  following  advantages  as  compared 
with  the  older: 

1.  The  citrate  method  is  technically  as  easy  as  an  ordinary  saline 
infusion,  therefore,  it  does  not  require  any  special  skill. 

2.  The  donor  and  recipient  are  not  in  the  same  room,  which 
lessens  the  psychic  shock  for  the  patient.  Furthermore,  it  eliminates 
the  risk  of  infecting  the  donor  in  cases  of  sepsis. 

Perhaps  no  one  is  more  adept  at  carrying  out  the  citrate  trans- 
fusion than  J.  de  J.  Pemberton  of  Eochester,  hence,  I  give  in  ex- 
tenso,  his  technic  as  related  at  the  1916  meeting  of  the  Minnesota 
State  Medical  Society. 

"Since  December,  1915,  we  have  been  using  the  citrate  method 
almost  exclusively  and  in  this  series  we  have  employed  it  in  217 
cases.  The  criticisms  of  the  method  such  as  the  resulting  polyuria, 
the  crenation  of  the  red  corpuscles,  the  idiosyncrasies  to  citrate, 
the  exposure  of  the  blood  to  air  and  contamination,  are  all  un- 
substantiated in  the  clinical  application  of  the  method.  In  no  patient 
have  we  seen  following  the  transfusion  any  untoward  effect  which 
could  be  attributed  to  the  toxicity  of  the  drug.  The  simplicity  and 
sureness  of  technic,  the  safety  of  its  employment  and  the  proved 
therapeutic  value  of  the  citrated  blood  should  recommend  the 
method  for  a  more  extensive  adoption. 

"The  arm  of  the  donor  is  prepared  in  the  usual  manner,  a 
tourniquet  is  lightly  applied  above  the  elbow  and  the  vein  (medium 


(ill) 


after-tri:atmi-;nt  of  surgical  patients 


cephalic  or  medium  basilic)  is  either  punctured  with  a  large-sized 
needle  or  exposed  by  a  small  incision  and  a  cannula  introduced 
(Fig.  205).  By  a  simple  yet  very  ingenious  little  trick  advised  by 
Watson,  we  have  been  aided  greatly  in  introducing  a  large-sized 
Kaliski  (gauge  11)   needle  (Figs.  206  and  207)    into  the  lumen  of 


Fig.    JO?. — Citrate   transfusion    as   done   by    Pcmberton. 


the  vein.  By  means  of  a  small  straight  intestinal  needle  inserted 
transversely,  the  vein  is  transfixed  to  the  skin,  the  needle  passing 
through  its  upper  segment  (Fig.  208).  With  the  end  of  this  trans- 
fixing needle  as  a  handle,  the  vein   is  then  steadied  and  the  can- 


BLOOD    TRANSFUSION 


611 


nula  needle,  directed  parallel  with  the  line  of  the  vein,  can  be 
readily  pushed  beneath  the  level  of  the  transfixing  needle  into  the 
lumen  of  the  vein  (illustration).  The  blood  is  received  in  a  sterile 
graduated  glass  jar  containing  30  cubic  centimeters  of  a  2  per  cent 


- 

1         ' 

Fig.   206.— The   Kaliski   needle. 


■  j 

. 

.       * 

!             \mmmm 

J      n     ! 

, 

Fig.    207. — The    Kaliski    needle    separated    into    its    component    parts. 

sterile  solution  of  sodium  citrate  at  the  bottom  (Fig.  209).  While 
the  blood  is  running  it  is  well  mixed  with  the  citrate  solution  by 
means  of  a  glass  rod.  After  the  blood  has  reached  the  250  cubic 
centimeter  mark,  another  30  cubic  centimeters  of  the  citrate  solution 


612 


AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 


is  added  and  the  blood  permitted  to  flow  until  there  are  500  cubic 
centimeters  of  the  mixture.  If  more  blood  is  desired,  a  sufficient 
amount  of  the  citrate  solution  is  added  to  maintain  this  ratio  of 
.2  per  cent. 

"The  blood  may  be  carried  to  the  recipient's  room  or  the  re- 
cipient brought  into  the  operating  room.  The  needle  is  then  in- 
troduced into  the  recipient's  vein  or  the  vein  is  exposed  by  a  small 
incision  (Figs.  210-214).  The  cannula  is  introduced  and  attached  to 
;i   funnel  or  "lass  irrigating  flask.     The  rubber  tubing  and  the  bot- 


-\ 


S  Kin 


Von  or 


Fig.   208.— The   transfusion    needle   introduced   by   the   vein   transfixing   method.      (After   Pem- 

berton.) 


lorn  of  the  flask  arc  filled  with  saline  solution  to  prevent  air  from 
getting  into  the  circulation.  The  citrated  blood  is  then  transferred 
into  the  Hash  and  permitted  to  How  into  the  vein  of  the  recipient 
(Figs.  215-217).  There  is  no  occasion  for  hurry  as  the  blood  will 
not  clot.  On  the  other  hand,  it  is  advisable  to  have  the  blood  run 
in  slowly  in  order  to  guard  againsl  suddenly  overloading  the  right 
heart  and  in  order  to  watch  for  any  untoward  effect  upon  the  pa- 
tient. The  marked  slowing  of  the  pulse,  syncopal  attacks,  dyspnea. 
cyanosis,    sensation    of    cardiac    oppression    or    excruciating    pains 


BLOOD    TRANSFUSION 


613 


throughout  the  body,  especially  localized  in  the  small  of  the  back, 
should  be  interpreted  as  danger  signals,  and  if  these  persist  after 
temporary  stopping  of  the  flow,  it  is  advisable  to  conclude  the  op- 
eration at  once." 

I  failed  of  a  result  in  two  instances  because  the  mixture  of  blood 
and  citrate  solution  clotted.  Knowing  of  Dr.  Pemberton's  success 
in  hundreds  of  instances,  I  wrote  him  for  advice.  The  reply  re- 
ceived is  so  illuminating  that  I  give  it  in  full.17 

"In  perhaps  three  or  four  cases  I  have  met  with  the  complica- 


Fig.    209. — Mixing    the    blood    with    citrate    solution. 


tion  which  you  mention  of  having  the  blood  show  a  tendency  to 
coagulate.  In  two  consecutive  cases  the  blood  clotted  en  masse. 
This  was  proved  to  be  due  to  faulty  preparation  of  the  citrate 
solution  in  which  the  proper  percentage  of  citrate  was  not  made. 
The  other  instances  have  been  encountered  in  cases  in  which  the 
blood  does  not  flow  freely  from  the  vein  of  the  donor,  in  which  the 
tourniquet  has  been  improperly  applied,  when  the  vein  is  very  small 
or  iu  cases  where  the  patient  has  become  faint  and  blood  pressure 


614 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


has  fallen.  In  such  instances  there  is  very  likely  to  occur  some 
change  in  the  coagulability  of  the  blood  before  it  has  reached  the 
citrate  solution,  (probably  prothrombin  has  been  converted  into 
thrombin  .  and  when  the  mixture  has  been  allowed  to  stand  for  ;i 


Fig.  210. — The  recipient's  it  can  not  be  punctured. 


c 


vein    where    skin    incisi< 

short  time  clotting  takes  place.     Of  course  these  eomplications  can 
be  easily  prevented." 

Lewisohn18  wrote  in   1  !•  1 7  that  "five  gm.  of  sodium  citrate  can 
be  introduced  safely  into  an  adult.     Larger  amounts  are  extremely 


BLOOD    TRANSFUSION 


615 


toxic.  We  rarely  transfuse  more  than  1000  c.c.  of  blood,  which 
"would  represent  2  gm.  of  sodium  citrate.  However,  even  a  trans- 
fusion of  1500  c.c.  of  blood  would  require  only  3  gm.  of  sodium 
citrate,  a  perfectly  safe  dosage." 

"With  this  in  mind,  I  have  in  my  recent  work  ventured  to  modify 
the  original  procedure  to  the  extent  of  using  50  c.c.  of  3  per  cent 
sodium  citrate  to  each  500  c.c.  of  blood.  I  have  been  uniformly 
successful  since  doing  this  and  feel  that  I  can  recommend  the 
modification  as  tending  to  facilitate  the  procedure  and  to  render 
the  result  certain.  The  citrate  method  is  believed  by  us,  destined 
to  supersede  all  the  others.  The  latter  are  not  recommended  as  its 
equals,  but  given  merely  for  the  sake  of  completeness. 


Fig.  212. — A  form  of  cannula  which  may  be  tied  in  recipient's  vein  if  not  punctured. 


I  have  no  wish  to  confuse  my  readers  by  giving  methods  which 
I  do  not  recommend  or  use,  but  feel  that  knowledge  of  the  subject 
requires  a  perusal  of  the  work  of  Satterlee  and  Hooker,19  who 
employ  pipettes  which  have  been  coated  with  20  to  30  c.c.  of  a 
10  per  cent  solution  of  sodium  citrate.  The  fluid  is  poured  into  the 
pipette  just  previous  to  use  and  by  rotating  the  instrument  in  a 
horizontal  position,  the  interior  is  thoroughly  coated.  The  excess 
is  allowed  to  drain  out  through  the  tip,  leaving  about  1  c.c.  of  the 
solution  which  adheres  as  a  thin  film  to  the  glass  wall  of  the  cylin- 
der. This  amount  of  sodium  citrate  (100  mg.)  is  sufficient  to  trans- 
fuse 250  c.c.  of  blood  when  used  with  their  cannula,  and  the  only 


61G 


AFTER-TREATMEXT    OF    SI   RGK  AL    PATIENTS 


Fig.  21  entering  recipient's  vein. 


BLOOD    TRANSFUSION 


617 


fully  citrated  blood  is  the  small  (about  12  c.c.)  residual  portion  which 
is  retained  in  the  pipettes.  Only  38  nig.  sodium  citrate  per  100  c.c. 
of  blood  is  necessary  for  transfusion  by  this  technic. 

Weil20  combines  the  syringe  and  anticoagulant  methods  in  this 
way:  the  blood  is  aspirated  from  a  vein  and  is  at  once  well  mixed 
with  sodium  citrate  in  a  10  per  cent  solution  in  water,  in  the  pro- 
portion of  1  c.c.  of  solution  to  10  c.c.  of  blood.  If  the  mixture 
is  made  in  the  syringe  in  eases  in  which  not  more  than  50  c.c. 
are  to  be  transfused,  the  transfer  can  be  made  directly  from  donor 


Fig.  215. — Funnel  tube  and  a  form  of  cannula  which  can  be  used  on  recipient. 


to  donee.  If  larger  amounts  are  to  be  used,  the  blood  is  expelled 
into  a  flask,  from  which  the  syringe  is  filled.  In  drawing  the  blood 
it  is  well  to  use  a  three-way  stopcock  having  communications  with 
the  needle,  with  a  10  c.c.  syringe  containing  the  citrate  and  with  a 
large  aspirating  syringe. 

Kimpton  and  Brown21  have  devised  a  method  which  in  point  of 
usefulness  stands  next  to  that  of  Lewisohn  (citrate).  Their  appa- 
ratus consists  of  a  glass  cylinder  of  whatever  size  desired,  (300 
to  600  c.c),  closed  at  the  upper  end  by  a  cork  stopper,  having  a 


618 


AFTER-TREATMENT    OF    SURGICAL   PATIENTS 


side  tube  a  little  below  the  cork,  and  a  cannula  leading  from  the 
bottom  of  the  cylinder  at  such  a  curve  that  it  will  lead  from  the 


Fig.    216.— Th 


Fig.    21!  venient   compress   which    is   included    in    the    ends   of    the    suture. 


upper  convexity  of  the  cylinder  when   the  latter  is  placed  on   its 
side  with  the  so-called  side  tube  uppermost. 


BLOOD    TRANSFUSION  619 

"The  cannula  bends  downward  just  after  leaving  the  cylinder 
at  a  right  angle.  From  the  last  bend  the  cannula  should  not  be  more 
than  2  or  3  inches  long,  should  taper  gradually,  and  terminate  in  a 
beveled  and  burnished  point  about  2  or  3  mm.  in  diameter. 

"A  small  piece  of  pure,  clean  paraffin  (melting  point'  50°  C, 
122°  F.)  is  placed  in  the  cylinder  and  the  cork  pushed  into  place. 
The  whole  cylinder  is  then  wrapped  carefully  in  a  towel,  placed  on 
its  side  in  an  autoclave  and  sterilized  in  the  same  manner  as  are 
dressings.  At  the  time  of  the  operation,  the  sterile  tube  is  unwrapped 
by  the  surgeon  and  held  above  the  flame  of  a  Bunsen  burner  (Fig. 
218),  alcohol  lamp,  or  other  source  of  heat,  and  carefully  revolved  un- 
til the  melted  paraffin  has  covered  all  portions  of  the  inner  surface 
of  the  cylinder,  cork,  and  the  side  tube  as  far  as  the  constriction. 


Fig.    218. — Paraffin    coating    in    process    of    application. 

Finally  the  excess  is  allowed  to  run  out  of  the  cannula,  while  the 
tip  is  held  against  a  sterile  gauze  sponge.  To  avoid  excessive 
crystallization  of  the  paraffin,  the  cylinder  should  be  cooled  as 
quickly  as  possible  by  being  brought  into  contact  with  the  operator's 
hands.  A  small  piece  of  sterile  absorbent  cotton  is  next  loosely 
inserted  into  the  side  tube  as  far  as  the  constriction,  to  prevent 
contamination  from  the  air,  and  the  cylinder  is  ready  for  use. 
Convenient  veins  of  both  donor  and  recipient  having  been  bared 
previously,  a  ligature  is  thrown  around  the  donor 's  vein  proximally 
and  around  that  of  the  recipient  distally.  Traction  is  made  on  the 
ligature  around  the  vein  of  the  donor,  thereby  elevating  the  vein, 
which  is  opened  longitudinally  with  a  cataract  knife.  The  edges 
of  the  incision  are  held  apart  with  mosquito  forceps,  small  tissue 


620 


AFTER-TREATMENT    OP    SURGICAL   PATIENTS 


forceps  or  fine  hooks,  and  the  tip  of  the  tube,  directed  peripherally, 
is  inserted  into  the  lumen  of  the  vein.  The  donor  is  directed  to 
open  and  close  the  hand  slowly,  and  this  pumping  effect  causes  the 
tube  to  fill  very  quickly  (Fig.  219).  A  ligature  around  the  arm 
above  the  incision  will  increase  the  rapidity  of  flow,  but  its  use  is 


Fig.    219. — Blood    running   into    tube    from    donor. 


not  always  necessary.  The  vein  of  the  recipient  is  now  opened 
and  the  tip  of  the  tube  inserted,  directed  centrally.  The  cautery 
bull)  previously  sterilized  or  the  operator's  mouth  (Fig.  220)  is  at- 
tached to  the  side  tube  and  very  slight    pressure   is  exerted.     The 


BLOOD    TRANSFUSION 


621 


blood  flows  into  the  vein  at  a  rate  which  is  always  under  the  con- 
trol of  the  operator." 

If  more  blood  is  desired,  the  operation  is  repeated  with  a  fresh 
tribe,  otherwise  nothing  remains  to  be  done  except  to  close  the 
small  wounds  made  in  exposing  the  veins.  The  advantages  claimed 
for  this  method  are: 

1.  Known  quantity  of  blood  may  be  administered. 

2.  As  much  as  1600  c.c.  can  be  given  in  5  to  8  minutes. 

3.  Venous  blood  is  utilized,  so  that  arteries,  such  as  the  radial 
are  not  destroyed. 


Fig.    220. — Blood    being   driven   into    recipient's   vein. 


4.  Transfusion  may  be  made  without  contaminating  the  donor 
with  the  blood  of  the  recipient. 

5.  There  is  direct  communication  between  vein  and  chamber  by 
a  simple  paraffin  lined  glass  tube.  There  are  no  metal,  rubber  or 
other  connections,  whose  edges  cause  resistance  to  the  flow  of  blood. 

6.  The  apparatus  is  simple  and  can  be  made  by  any  good  glass 
blower. 

I  have  never  failed  with  this  method,  but  must  say  that  it  is  a 
real  surgical  operation.  On  the  other  hand,  any  physician,  not  an 
operator  can  do  a  citrate  transfusion. 


622 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


Percy12  reports  54  blood  transfusions  effected  by  means  of  a  one- 
piece  paraffin  lined,  glass  tube  i  Pig.  221),  holding  650  c.c.  of  venous 


i  1       The    Pi 


blood  protected  from  contact  with  air  by  a  floating  layer  of  sierile 
liquid  paraffin.     His  method  is.  in  reality,  an  enlargement   and  re- 


BLOOD    TRANSFUSION  »  623 

finenient  of  the  Kimpton-Brown  idea.  Percy  is  an  expert  operator 
and  does  his  transfusion  with  a  dexterity  that  will  never  be  at- 
tained by  most  men. 

Thies  first  suggested  the  reinjection  of  the  blood  that  collected  in 
the  abdominal  cavity  in  cases  of  ruptured  extrauterine  pregnancy. 
He  used  whole  blood  diluted  3  to  2,  with  normal  salt  solution  in 
three  cases  and  saved  them  all.  This  method  is  thought  too  danger- 
ous on  account  of  embolism,  so  Lichtenstein22  injected  8  patients 
only  after  the  blood  had  been  mixed  with  a  little  Einger's  solution 
and  defibrinated.  During  the  process  of  defibrination  and  all  the 
time  the  blood  was  out  of  the  body,  it  was  kept  warm  (body  tem- 
perature) by  being  surrounded  by  warm  water.  After  the  abdom- 
inal operation  the  blood  was  injected  into  a  vein  in  the  arm.  Lieh- 
tenstein  uses  a  contrivance  similar  to  a  salvarsan  apparatus  and 
finds  that  it  works  well. 

Henschen  collects  the  blood  in  paraffined  receptacles,  strains  it 
through  paraffined  gauge,  or  adds  sodium  citrate  and  then  reintro- 
duces it  into  a  vein  with  the  Percy  transfusion  instrument. 

I  feel  compelled  to  caution  the  reader  who  intends  to  transfuse 
for  the  immediate  treatment  of  profuse  hemorrhage,  that  there  is 
always  danger  of  a  sudden  rise  in  blood  pressure,  leading  to  re- 
newed bleeding  from  the  original  source,  provided  the  hemorrhage 
is  not  known  to  have  been  accurately  controlled.  AVe  cruestion  the 
advisability  of  transfusion  where  bleeding  is  in  progress,  when  it 
has  been  controlled  by  packing,  or  when  it  has  ceased  spontaneously 
upon  lowering  of  blood  pressure. 

A  caution  regarding  the  danger  of  plethora  may  not  come  amiss. 
Too  voluminous  or  too  rapid  a  transfusion  may  not  only  exhaust 
the  donor  but  kill  the  recipient,  hence,  critical  observation  of  both 
must  be  maintained,  regardless  of  the  method  used. 

AVhen  a  donor  evinces  faintness  or  shortness  of  breath,  he  has 
reached  the  danger  point.  Danger  signals  from  the  recipient's  side, 
will  be  referable  to  the  heart:  Adz.,  precordial  distress,  restlessness, 
and  shortness  of  breath.  On  examination  there  will  be  found  fast 
pulse  or  later  gallop  rhythm,  increased  absolute  cardiac  dullness  to 
the  right,  prominence  of  superficial  veins,  general  cyanosis,  and 
lastly  subcrepitant  rales,  denoting  pulmonary  edema. 

As  Pemberton  writes:  "There  are  two  other  well-recognized  ac- 
cidents associated  with  and  complicating  blood  transfusion,  namely, 
embolism  from  introduction  of  air  or  clotted  blood  and  hemolysis. 
The  first  of  these  is  absolutely  preventable  by  the  exercise  of  due 
caution  as  to  the  technic.     The  third  danger  due  to  the  incompati- 


624  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

bility  of  the  blood  of  the  donor  and  the  blood  of  the  recipient,  while 
controllable  to  a  remarkable  degree  by  preliminary  blood  tests,  is 
not  an  absolutely  preventable   complication." 

I  can  not  call  this  chapter  complete  without  mention  of  hemo- 
lysis occurring  at  a  time  when  we  chance  it  as  the  lesser  of  two 
evils. 

Pemberton  writes:  "In  an  emergency  such  as  that  following  an 
acute  hemorrhage  when  the  life  of  the  patient  is  dependent  on  an 
immediate  transfusion,  Ave  are  justified  in  using  a  donor  without 
a  preliminary  test.  In  such  instances  the  operator  should  permit 
the  first  200  c.c.  of  blood  to  run  in  slowly.  If  the  patient  shows 
symptoms  of  hemolysis  as  evidenced  by  suffusion  of  the  face,  dysp- 
nea, syncopal  attacks,  marked  slowing  of  the  pulse  rate  and  ex- 
cruciating pains  in  the  back,  the  operation  should  be  concluded  or 
another  donor  secured." 

After  this  chapter  had  been  senl  to  the  publisher  my  coworker. 
Dr.  George  W.  Ives  very  kindly  consented  to  contribute  an  up-to- 
the-minute  resume  of  the  subject,  which  follows: 

The  Selection  of  Donors  for  Transfusion 

It  is  obvious  thai  for  donors  healthy  adult  individuals  should  be 
selected  whenever  possible.  Particular  care  should  be  exercised 
not  to  selecl  as  a  donor  an  individual  who  is  suffering  from  syphilis, 
malaria,  or  any  other  disease  which  may  be  transmitted  by  blood 
transfusion. 

Of  even  greater  importance,  as  regards  the  immediate  interests  of 
the  patient,  is  the  desirability  that  the  donor's  blood  be  compatible 
with  that  of  the  recipient.  Serious  symptoms,  and  even  death,  have 
occasionally  so  closely  followed  t  ranst'usions  as  to  indicate  that  they 
are  ihe  result  of  the  procedure.  It  is  wry  probable  that  nearly  all 
serious  effects  of  transfusion  can  he  attributed  to  the  administra- 
tion of  incompatible  blood. 

The  accompanying  diagram  on  page  625,  which  was  devised  by  San- 
ford.-1  I  have  found  of  extreme  value  in  gaining  a  comprehension 
of  blood  grouping  as  regards  isoagglutinins ;  and  without  this  dia- 
gram, I  have  usually  found  it  impossible  to  make  the  subject  elear 
to  students  and  clinicians.  As  a  practical  proposition  isohemoly- 
sins  may  be  neglected,  since  when  they  are  present,  they  fall  into 
groups  which  parallel  the  isoagglutinin  groups. 

Among  other  facts,  the  diagram  illustiates  that  all  individuals 
may   he  divided  into  four  groups  as  regards  the   presence  of  iso- 


BLOOD    TRANSFUSION  625 

hemagglutinins  in  the  blood  serum.  Group  I  includes  those  per- 
sons who  hare  no  agglutinin,  and  constitutes  10  per  cent  of  all  in- 
dividuals; Group  II  includes  those  who  possess  agglutinin  "A," 
and  constitutes  40  per  cent  of  all  individuals.  Group  III  includes 
those  who  possess  agglutinin  "B,"  and  constitutes  7  per  cent  of 
individuals;  and  Group  IV  constitutes  13  per  cent  of  individuals, 
and  they  possess  both  agglutinin  "A"  and  agglutinin  "B." 

A  fundamental  conception  in  an  understanding  of  these  blood 
relationships  is  this  self-evident  fact:  The  corpuscles  of  a  person 
are  immune  to  the  agglutinin  or  agglutinins  which  may  be  present 
in  their  blood  serum.  Experiment  has  taught  that  corpuscles  are 
always  susceptible  of  agglutination  by  any  agglutinin  which  is  not 
naturally  present  in  their  serum. 

From  these  facts  it  follows  that  Group  I  serum  will  not  aggluti- 
nate the  corpuscles  of  any  of  the  groups;  that  Group  I  corpuscles, 


[7Jo  Agg  luTinin  )       ( I  Agglutinin  )~3" 
[ID  fi  of  all perscns)    (J%  of  all  persons} 

X  K * \Jir 


3Z. 


(l/feglutin/n)   "A"     (BoTh  agglutinins)'*)"*'!}" 
{1D%  of  all  persons)    [AJfo  of  ail  persons) 


since  they  are  not  protected  against  either  agglutinin  "A"  or  "B," 
will  be  agglutinated  by  the  serums  of  the  other  three  groups;  that 
Group  II  serum,  because  of  the  presence  of  agglutinin  "A,"  will 
agglutinate  the  corpuscles  of  both  Group  I  and  Group  III,  but  it  will 
have  no  effect  on  Group  IV  corpuscles,  as  they  are  protected  against 
agglutinin  "A;"  that  Group  III  serum  will  agglutinate  the  cor- 
puscles of  Group  I  and  Group  II,  but  it  will  have  no  effect  on  Group 
IV  corpuscles,  as  they  are  protected  against  agglutinin  "B;"  Group 
IV  serum  will  agglutinate  the  corpuscles  of  the  three  other  groups 
because  Group  I  corpuscles  are  susceptible  to  both  agglutinins, 
Group  II  corpuscles  are  susceptible  to  agglutinin  "B."  and  Group 
III  corpuscles  are  susceptible  to  agglutinin  "A." 

A  prospective  donor's  blood  presents  three  possibilities  of  rela- 
tionship to  a  prospective  recipient's  blood;  viz.,  (1)  The  relation- 
ship is  called   ideal  when  donor  and  recipient  belong  to  the  same 


626  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

group;  (2)  The  relationship  is  suitable  when  they  belong  to  differ- 
ent groups,  and  when  the  recipient's  serum  will  not  agglutinate  the 
corpuscles  of  the  donor;  (3)  The  donor  is  definitely  not  suitable 
when  his  corpuscles  are  agglutinated  by  the  serum  of  the  prospec- 
tive recipient.  I  know  of  no  evidence  which  definitely  disproves 
my  tentative  belief  that  from  a  practical  standpoint  the  relation- 
ship in  the  second  instance  is  as  ideal  as  when  donor  and  recipient 
belong  to  the  same  group.  If  this  is  true,  the  only  contraindication 
to  blood  transfusion,  on  the  basis  of  blood  relationships,  is  the  third 
relationship. 

A  close  analysis  of  the  statements  set  forth  shows  that  as  a  prelim- 
inary to  transfusion,  the  grouping  of  the  donor  or  recipient  is  nor 
imperative.  The  only  requirement  is  that  the  recipient's  serum  docs 
not  agglutinate  the  donor's  corpuscles.  It  is  highly  advantageous 
in  many  instances  that  the  grouping  of  the  recipient  and  the  donors 
be  known.  As  it  requires  no  more  labor  to  determine  the  grouping 
than  it  does  to  determine  the  minimum  information  which  is  re- 
quired, it  is  my  practice  to  always  determine  the  groups.  This  i> 
easily  carried  out  when  a  "standard"  blood  is  available,  and  it 
possesses  the  advantage  that  an  individual  who  is  once  grouped 
need  not  at  a  subsequent  time  lie  tested,  whether  he  is  a  recipient  or 
a  donor. 

Besides  facts  previously  stated.  Sanford's  diagram  illustrates  the 
following  important  points:  Group  I  individuals  may  receive  the 
blood  of  the  same  group,  and,  as  indicated  by  the  arrows,  the  blood 
of  all  other  groups.  Any  one  may  he  a  donor  for  10  per  cent  of 
persons  (Group  [).  Group  II  may  receive  the  blood  of  both  Group 
II  and  Group  IV.  Forty  per  cent  of  individuals  may,  Iherefore, 
receive  the  blood  of  83  per  cent  of  all  persons.  Group  III  may  re- 
ceive the  blood  from  Groups  III  and  IV,  or  50  per  cent  of  all  per- 
sons may  be  donors  to  this  group.  Group  IV  may  receive  only 
Group  IV  blood,  hence,  the  Largesl  group  has  the  smallest  number 
of  suitable  donors,  but  the  members  of  this  group  may  be  donors 
to  the  members  of  all  the  groups.  Hence,  if  a  Group  IV  donor  is 
available,  it  is  not  imperative  that  the  grouping  of  the  recipient  be 
determined,  and  if  it  is  known  thai  the  recipient  belongs  to  (I roup 
I,  it  is  unnecessary  to  determine  the  grouping  of  the  donor. 

Several  methods  for  group  determination  have  been  proposed. 
Certainly,  a  method  which  possesses  simplicity,  which  furnishes  all 
the  information  desired,  which  requires  a  minimum  of  time,  which 


BLOOD    TRANSFUSION  627 

requires  minimum  amounts  of  blood,  and  which  requires  no  special 
apparatus,  should  he  selected  in  preference  to  those  methods  which 
give  less  certain  and  less  rapid  results,  and  which  require  more 
labor  and  considerable  amounts  of  blood. 

The  writer  recommends  the  method  of  Brem24  because  it  possesses 
the  following  advantages:  (1)  It  gives  the  complete  information  re- 
quired. (2)  The  test  is  performed  with  ordinary  apparatus.  (3)  It 
requires  less  than  thirty  minutes  in  a  laboratory  where  these  tests 
are  commonly  made.     (4)  It  requires  only  a  few  drops  of  blood. 

Brem's  method  may  be  used  either  to  determine  the  suitability 
of  the  donor's  blood  without  grouping,  or  it  may  be  used  to  deter- 
mine the  grouping.  For  the  purpose  of  the  latter  determination, 
either  Group  II  or  Group  III  blood  must  be  available.  This  known 
blood,  with  which  the  unknown  bloods  are  matched,  is  called  the 
"standard."  Two  centrifuge  tubes  are  required  for  the  "stand- 
ard" blood,  and  two  for  the  blood  of  each  person  to  be  tested.  The 
first  tube  of  each  pair  should  be  clean  and  dry,  and  the  second  tube 
should  contain  about  1  c.c.  of  one  per  cent  sodium  citrate  in  0.85 
per  cent  sodium  chloride. 

The  blood  is  obtained  preferably  from  a  finger.  Into  the  first 
tube  about  ten  drops  of  blood  are  collected.  One  or  two  drops  are 
obtained  for  the  second  tube,  and  immediately  it  is  mixed  with  the 
fluid  in  that  tube.  The  corpuscles  should  again  be  well  mixed, 
just  before  they  are  used.  After  the  blood  specimens  in  the  first 
tubes  of  each  pair  have  clotted,  the  clot  is  separated  from  the  glass 
by  means  of  a  platinum  wire,  and  the  tubes  are  then  centrifugalized 
until  the  serums  are  clear. 

For  a  group  determination,  each  blood  requires  two  hanging  drop 
preparations.  The  concavities  of  the  slides  should  be  rimmed  with 
vaseline  for  the  following  reasons:  (1)  The  vaseline  seals  the  cham- 
bers and  prevents  the  evaporation  of  the  preparations.  (2)  It  holds 
the  inverted  coA^er  glasses  on  the  slides.  (3)  It  enlarges  the  cham- 
ber for  the  hanging  drop. 

The  test  is  performed  and  the  results  interpreted  as  indicated  by 
the  following  scheme: 

Groups 


/i  hi     ii  Til 

2Loops  Group  2.   Serum  +  i 'Loop  (?)  Serum*- 1  Loop  (?)  Gorp  ~     4-  J—  '  •—'-♦- 
2  Loops!  ?)  Serum  +  I Loop  Group  2  Strum + 1  Loop  GroupQ  Corp=  •+  J  —  \-h\  — 


628  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

In  each  preparation,  our  loop  of  serum,  corresponding  to  the  cor- 
puscles of  that  preparation,  is  used.  The  purpose  of  this  serum  is 
to  protect  the  corpuscles  against  hemolysis. 

In  the  above  scheme  (?)  indicates  "unknown,"  (+)  indicates 
"agglutination,"  and  (-)  indicates  "no  agglutination."  It  will  be 
noted  that  with  an  unknown  blood  four  results  arc  possible.  If  in 
both  preparations  there  is  agglutination,  the  tested  blood  belongs  to 
Group  III.  This  is  made  clear  by  reference  to  Sanford's  diagram, 
which  indicates  thai  a  blood  whose  serum  agglutinates  Group  II 
corpuscles  and  whose  corpuscles  are  agglutinated  by  Group  11 
serum,  belongs  to  Group  I1T.  If  there  is  no  agglutination  in  either 
preparation,  the  tested  blood  belongs  to  Group  II.  If  the  first  prep- 
aration shows  no  agglutination,  and  the  second  does  show  aggluti- 
nation, the  unknown  belongs  to  Group  IV.  If  the  first  preparation 
shows  agglutination  and  the  second  does  not,  the  tested  blood  be- 
longs to  Group  I. 

To  increase  the  rapidity  and  accuracy  of  the  test,  the  following 
suggestions  may  be  of  service  to  the  beginner.  The  whole  blood 
specimens  should  be  allowed  to  clot  completely,  otherwise  plasma 
will  be  used  in  the  test  and  a  clot  may  form  on  the  cover  glasses, 
which  will  prevent  agglutination.  The  serums  should  be  free  from 
corpuscles.  A  proper  loop  should  be  used.  This  is  one  which  takes 
up  and  delivers  a  uniform  drop.  The  loop  should  be  flamed  before 
passing  it  from  one  blood  specimen  to  another.  After  the  required 
drops  are  placed  on  a  cover  glass,  the  various  drops  are  thoroughly 
mixed  with  the  loop  and  then  the  preparation  is  inverted  over  the 
concavity  of  the  slide.  If  the  slides  are  gently  rocked  or  rolled, 
agglutination  will  be  greatly  accelerated  and  the  results  may  be 
known  in  a  very  few  moments  in  nearly  every  instance.  Time  ag- 
glutination is  characteristic,  it  is  rapid  and  should  not  be  mistaken 
for  rouleaux  formation. 

Full  credit  is  due  0.  P.  MeKittrick  for  having  abstracted  all  the 
literature  to  which  reference  is  made  in  this  chapter. 

Bibliography 

LMcClme  and  Dunn:      Bull.  .Johns    Hopkins  Hosp.,   xviii.  No.   313. 

-Lamlois:     Transfusi les  Blutes,   Leipsig,    L875. 

■  Willinotli :     Am.  Jour.   Surg.,    L916,  xxx,    L47. 
tMedico-Chirurgical    Transactions,    L918,   ix,   56. 
sPersona]   Communication,   Mayo   Clinic,    1916. 
gMoss:     Bull.  Johns  Hopkins  Bosp.,  March,  L910. 
?Minot:      Boston   Med.  and  Surg.  Jour.,  1916,  clxxiv,  667. 
sLindeman:     .lour.   Am.  Med.  Assn.,   L916,  Ixvi,  624. 


BLOOD    TRANSFUSION  629 

oOttenberg  and  Libinan:     Am.  Jonr.  Med.  Sc,  1915,  cl,  36. 

loLewisohn :      Surg.,  Gynee.  and  Obst.,   1915,  xxi,   37. 

uDeaver:     Am.  Jour.  Burg.,  1915,  xxix,  10. 

izPerey:     Surg.,  Gynee.  and  Obst.,  1915,  xxi,  360. 

isHartwell:     New  York  State  Med.  Jour.,  1914,  xiv,  535. 

i^Krida:     Albany  Med.  Ann.,  1916,  xxxrii,  161. 

i5Lindeman:     Jour.  Am.  Med.  Assn.,  xliii,  1542. 

"Miller:     Long  Island  Med.  Jour.,  1916,  x,  1S9. 

I'Pemberton:     Personal  communication. 

isLewisohn:     Jour.  Am.  Med.  Assn.,  March  17,  1917. 

isSatterlee  and  Hooker:     Jour.  Am.  Med.  Assn.,  Feb.  26,  1916. 

20 Weil:     Jour.  Am.  Med.  Assn.,  1915,  lxiv,  425. 

siKimpton:     Boston  Med.  and  Surg.  Jour.,  1913,  clxix,  783. 

22Lichtenstein :     Miinchen  med.  Wchnschr.,  1915,  lxii,  1597. 

23,Sanford,  A.  H. :  Isoagglutination  Groups,  A  Diagram  Showing  Their  Inter- 
relation, Jour.  Am.  Med.  Assn.,  Sept.  9,  1916,  p.  808. 

24Brem:  W.  V. :  Blood  Transfusion  with  Special  Reference  to  Group  Tests, 
Jour.   Am.  Med.   Assn.,   July,   1916,   p.   190. 


CHAPTER  LVIII 

THE  RECONSTRUCTION  OP  THE  PATIENT 
By  Robert  S.  Carroll,  Asheville,  North  Carolina 

The  last  dressing  lias  been  made,  the  last  surgical  advice  has  been 
given,  and  with  too  many  operators  the  fact  of  a  satisfactory  surgi- 
cal recovery  transfers  the  patient  into  the  limbo  of  the  dismissed. 
Unquestionably,  most  traumatic  cases  can  be  discharged,  not  only 
"recovered,"  but  well,  when  the  surgeon  or  his  assistant  makes  the 
last  visit.  Many  of  the  acutely  ill  are  promptly  restored  to  satisfy- 
ing health  through  the  surgeon's  interventions;  ever  and  anon  he 
performs  miracles  in  rescuing  chronic  sufferers  from  beds  of 
torture;  bul  all  too  frequently  the  most  astute  surgical  skill  leaves 
the  patient  mechanically  repaired  but  far  from  well —  sadly  lacking 
that  robustness  of  health  which  should  be  the  crowning  p-ift  of  medi- 
cal science.  There  will  ever  be  operators,  unfortunately,  who  can 
be  ranked  as  high-grade  mechanics  only,  operators  who  have  never 
seen  and  never  will  see  deeper  into  their  patient's  life-processes  than 
can  be  revealed  by  the  dissection  of  their  scalpels.  But  not  so  with 
the  true  surgeon.  He  recognizes  that  behind  many  cases  of  ap- 
pendicitis, gall  bladder  infections,  gastric  and  duodenal  ulcers,  in- 
tractable  neuralgias,    1 joint   and    soft    tissue   infections   lies   a 

depraved  metabolic  chemistry.  He  recognizes  that  thousands  of 
lives  of  comparative  inadequacy,  of  practical  uselessness,  lives  of 
continuing  years  of  discomfort  or  actual  suffering  persist  even  after 
the  best  surgical  skill  has  been  utilized  in  their  behalf.  The  modern 
surgeon  is  awaking,  even  as  the  entire  medical  profession,  to  the 
fundamental  influence  of  nutritional  disturbances  as  they  modify 
health,  disease  and  recovery,  and  is  recognizing  thai  it  is  his  or  his 
assistant's  duty  to  so  direct  the  patient  that  recovery  may  mean 
health.  The  discerning  surgeon  also  recognizes  that  oilier  thou- 
sands, whom  our  modern  intense  civilization  is  multiplying,  are  ever 
seeking  here,  there  and  yonder,  relief  from  symptoms  which  are  but 
the  expression  of  over-reacting  mentalities — hypersensitive,  sug- 
gestible  neurotics.  The  dramatic  elemenl  of  surgery  appeals  with 
peculiar  emphasis  to  the  nervously  inadequate,  but  Hie  most  astute 
surgical  refinements  leave  them  with  their  oversensitiveness  un- 
touched, with  their  capacity  for  nervous  suffering  unmitigated,  and 
l  heir  deficient  self-mastery  unrecognized  and  unhelped. 

G30 


RECONSTRUCTION    OF    THE   PATIENT  631 

Scrutiny  of  unsatisfactory  surgical  recoveries  shows  that  the  large 
majority  of  them  are  either  nutritionally  or  neurotically  inadequate, 
and  should  be  properly  grouped  in  one  or  both  of  these  classes.  The 
surgeon  who  is  satisfied  with  only  the  best  that  science  can  give  his 
patient  can  not  be  content  with  a  surgical  half-cure,  but  will  see 
to  it  that  each  of  his  cases  is  given  that  discriminating  analysis 
which  recognizes  the  basic  cause  of  the  baffling  and  depressing 
residuum  of  postsurgical  semiinvalidism. 

The  Nutritional  Reeducation. — In  our  land  of  wealth  and  plenty, 
abundance  of  the  good  things  of  life  has  been  at  the  command  of 
the  many  for  two  generations.  In  our  age  of  dazzling  mechanical 
progress,  the  forces  of  Nature  have  become  man's  servitors.  Abun- 
dance, even  superabundance,  to  eat  and  drink  is  the  common  lot — 
an  abundance  obtained  without  physical  effort.  Meanwhile,  the 
modern  brain  has  become  the  center  of  human  activity.  Steam, 
electricity,  and  petroleum  have  rendered  the  active  use  of  human 
muscle  needless.  Today  the  common  nutritional  defect  of  the  suc- 
cessful is  a  broken  food-oxidation  balance — food  oversupply,  with 
defective  muscle  activity.  This  is  evidenced  especially  in  the  per- 
sistent use  of  the  tissue-building  foods — absolutely  necessary  in 
youth  and  essential  to  the  muscle-laborer — but  continued  into  a  ma- 
turity which  knows  only  nervous  activity.  Such  faulty  dietary 
seldom  fails  .by  the  third,  usually  in  the  second  generation,  to  pro- 
duce a  disturbance  in  the  tissue  chemistry  which  complicates  every 
serious  operation,  and  frequently  makes  impossible  an  ideal  re- 
covery. And  so  each  painstaking  worker  today  will  know  the  sta- 
tus of  his  patient's  nitrogenous  equilibrium  not  only  by  a  series  of 
accurate  urea  estimates,  but  through  an  equally  careful  tabulation  of 
the  total  ammonia  elimination  indices.  Then,  as  will  often  be  the 
case,  if  the  evidence  of  unmetabolized  amino-acid  excess  is  revealed, 
clear-cut,  definite  and  far-reachingly  helpful,  practical  advice  in 
nutritional  readjustment  can  be  offered.  Such  a  condition,  of  course, 
means  a  reduced  alkaline  reserve.  This  relative  subacidosis  means 
defective  activity,  not  alone  of  kidneys  and  liver,  but  of  all  cell 
protoplasm.  In  such  cases,  appendix,  gall  bladder,  or  other  surgi- 
cal infection  is  but  an  incident  in  a  generalized  nutritional  defi- 
ciency. The  patient's  true  illness  is  a  lowering  of  the  vital  activity 
of  brain  cell,  muscle  tissue,  and  secreting  cells.  In  these  patients 
many  surgical  complications  occur — postoperative  vomiting,  un- 
expected infections,  persistent  anemias,  which  are  unquestionably 
due  to  reduced  phagocytic  activity.  Frequently  so-called  renal, 
hepatic,  and  pancreatic  insufficiencies  are  but  inadequate  terms  for 


632  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

a  far  more  deep-seated  protoplasmic  insufficiency,  secondary  to  the 
chronic  subintoxication  of  protein  malmetabolism.  It  is  astonishing 
how  many  comparatively  well  people  are  today  victims  of  the 
damage  of  protein  overfeeding,  and  were  it  not  that  so  large  a 
percentage  of  them  sooner  or  later  become  surgical  risks,  this  prob- 
lem would  he  entirely  within  the  province  of  the  internist. 

To  the  muscle  worker  many  foods  are  necessary  fuel,  which  for 
the  teacher,  merchant,  lawyer,  and  housewife  can  only  he  taken 
with  impunity  so  long  as  liver  and  kidneys  can  stand  the  strain  of 
forced  elimination.  In  our  probings  into  anatomic  and  physiologic 
recesses,  in  our  theories  and  findings  in  the  realm  of  ductless  glands 
and  the  specialized  activities  of  vicious  bacterial  strains,  our  pro- 
fession has  unwisely  neglected  the  profoundly  vital  metabolic  in- 
fluence of  thai  great  hulk  of  our  body — the  voluntary  muscles. 
Multiplied  pounds  of  unutilized  semiatrophic  tissue  hang  flabby,  a 
near-menace,  in  the  sedentary  individual — pounds  of  tissue  capable 
of  responding  quickly  to  physiologic  use.  pounds  of  tissue  capable 
of  returning  unbelievable  foot-tons  of  energy  to  the  man  or  woman 
who  will  give  that  care  to  muscles  which  will  raise  them  to 
their  possible  state  of  efficiency.  Other  than  fresh  air  and  sunshine, 
there  is  probably  no  medicine  so  certain  in  its  vitalizing  effect  as 
that  -which  comes  through  a  short  but  spirited  daily  use  of  muscles 
which  have  been  normally  developed  and  trained.  For  the  many 
who  have  never  been  so  developed,  and  who  have  added  insult  to 
injury,  year  after  year,  by  pouring  into  a  helpless,  patient  stomach 
the  tempting,  yet  disorganizing  viands  of  modern  culinary  skill,  a 
nutritional  reeducation  will  be  demanded.  This  can  not  be  done  in 
a  few  days.  bu1  is  best  accomplished  through  six  to  eight  weeks  of 
properly  ordered  resl  cure,  to  be  followed,  of  course,  by  other  weeks 
of  the  even  more  essentially  importanl  work  therapy. 

For  the  patient  who  is  looking  for  a  true  reconstruction,  the 
weeks  immediately  following  the  surgical  interference  are  espe- 
cially opportune.  Little  medicine  is  needed.  One  or  two  tablespoon- 
fuls  of  coarse  wheat  bran,  toasted  brown,  moistened  with  cream 
and  salted  to  taste,  taken  at  bedtime,  and  a  few  ounces  of  orange 
juice  or  equal  parts  of  orange  and  grape  fruit  pulp  taken  before 
breakfast  will  usually  keep  the  bowels  in  excellenl  condition.  Four 
ounces  of  mills  with  one  ounce  of  Vichy  water  every  two  hours  for 
seven  or  eighl  feedings  for  three  days,  with  milk  and  Vichy  rapidly 
increased  until  the  patient  is  getting  ten  ounces  of  milk,  two  ounces 
of  cream,  two  ounces  of  Vichy,  with  one.  two  or  even  three  raw  eggs 
each  feeding,  will  result  in  a  few  weeks  in  a  profound  nutritional 


RECONSTRUCTION    OF    THE   PATIENT  633 

reeducation.  Electricity  is  not  needed.  It  usually  overstiniulates 
the  nervous  patient  and  ultimately  exhausts,  and  except  as  a  psychic 
influence,  is  rarely  beneficial.  But  thorough  massage  for  half  an 
hour  morning  and  evening  is  a  most  excellent,  practically  a  neces- 
sary, adjunct.  Small  doses  of  a  stomachic,  as  tincture  of  calamus, 
or  gentian  compound,  or  better,  tincture  of  valerian  or  asafetida 
before  each  feeding  are  helpful  in  modifying  the  normally  active 
flatus  accompanying  this  regime.  Now  and  then,  especially  after 
the  raw  eggs  are  being  pushed,  suspension  of  one  or  two  feedings 
and  the  giving  of  one  ounce  of  castor  oil  may  be  necessary,  if  evi- 
dences of  overfeeding  are  present.  With  such  treatment  properly 
carried  out,  the  average  patient  will  gain  20  per  cent  in  weight  in 
seven  or  eight  weeks.  But  this  comfortably  fleshed,  thoroughly 
rested  patient  is  but  partially  reconstructed.  She  has,  however, 
appropriated  large  quantities  of  easily  digested  food,  and  with  this 
nutritional  reserve,  is  in  condition  to  receive  the  help  which  will  be 
essentially  lasting. 

The  transition  from  preparatory  rest  to  restoring  work  should 
be  started  slowly.  The  patient  may  sit  up  ten  minutes  the  first 
day,  increasing  ten  minutes  daily  to  one  hour,  and  twenty  minutes 
a  clay  thereafter.  When  up  an  hour,  ten  minutes'  walk  may  be 
taken,  to  be  increased  ten  minutes  a  day  to  one  hour.  The  average 
patient  can  walk  three  miles  comfortably  in  this  time.  The  next 
week  the  walking  may  be  increased  to  four  miles  and  the  following 
week  to  five.  Active  walking  should  be  continued  daily  for  a  num- 
ber of  months.  Other  physical  exercise  can  helpfully  be  under- 
taken when  the  patient  is  walking  three  miles,  any  active  out-of- 
door  work,  carpentering,  gardening,  shoveling  snow  in  winter, 
medicine  ball,  care  of  the  lawn — work  which  requires  active  mus- 
cular effort.  At  the  end  of  the  second  period  of  eight  weeks,  the 
majority  of  patients  should  be  really  robust,  fit  to  return  home  and 
stay  well  by  devoting  one  or  two  hours  a  day  to  earnest  muscular 
exercise.  Such  a  program  intelligently  but  firmly  carried  out  would 
restore  many  who  now  are  but  half  living — unworthy  products  of 
modern  professional  skill. 

Women  stand  in  more  frequent  need  of  the  nutritional  reeduca- 
tion here  outlined  than  men.  For  the  latter,  usually,  a  nutritional 
modification,  only,  is  necessary.  The  limiting  of  tobacco,  the  avoid- 
ance of  alcohol,  an  increase  in  oxidation  through  aggressive  and 
consistent  physical  effort,  a  decided  reduction  in  the  richer  protein 
foods— especially  after  thirty  years  of  age — and  a  definite  addi- 
tion of  an  alkaline-producing  dietary,  including  citrus  fruits,  whole 


G34  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

wheat  breads,  Irish  potatoes,  milk  and  legumes,  will  change  numbers 
of  unsatisfactory  cases  into  most  gratifying  cures.  Tt  is  possible  for 
many  who  are  now  almost  hopelessly  unfit,  under  such  a  regime, 
wisely  conducted,  to  attain  a  standard  of  physical  efficiency  which 
makes  it  possible  for  them  to  remain  strong,  robust,  and  adequate, 
with  even  a  daily  half-hour  devoted  to  intensive  exercise.  No  exer- 
cise can  be  considered  worthy  of  the  name  which  does  not  cause 
forced  breathing.  Ordinary  breathing  exercises  are  useless,  when 
compared  with  the  henefits  derived  from  the  panting  which  ac- 
companies active  effort.  The  counsellor  who  thus  advises  and  di- 
rects his  patient,  and  by  his  personality  inspires  him  to  so  alter  his 
habits  of  eating  and  exercise  thai  1  issue  metabolism  may  be  raised 
in  its  possible  high  potentiality,  offers  him  not  only  health,  hut  puts 
into  his  hands  thai  inestimable  boon,  super  health. 

The  Mental  Readjustment. — Unfortunately,  strength  of  physique 
does  not  always  insure  peace  of  mind.  Fears  and  worries  and  anx- 
ieties  may  depress  and  unnerve  the  strongest.  The  nervous  sys- 
tem is  constantly  reacting  to  its  surroundings.  Overresponsiveness 
or  misdirected  response  is  the  psychic  defect  which  makes  the  neu- 
rotic. Lack  of  menial  control  or  unwise  selection  of  the  objects  of 
attention  disturbs  the  nervous  health  and  serenity  of  strong  as  well 
as  weak.  Our  emotions  enter  into  all  our  nervous  reactions.  Every 
act  is  colored  or  discolored  by  our  feeling  tone.  A  hopeful,  opti- 
mistic outlook  adds  a  potenl  fighting  quality  to  every  surgical  case, 
while  a  doubting,  fearing,  complaining,  pessimistic  attitude  not 
only  robs  the  patient  of  a  certain  constructive  force,  but  dispirits 
operator  and  uurse  and  adds  a  handicap  to  the  entire  procedure 
which  must  be  reckoned  with.  To  most  of  us,  a  surgical  experience 
presents  a  strong  appeal  to  the  emotional  nature.  The  elements  of 
pain  and  danger  must  impress  even  the  most  phlegmatic,  while  in 
the  highstrung,  modern  neurotic,  the  capacity  to  calmly  and  ration- 
ally meet  the  operative  situation  is  rarely  attained.  The  thoughtful 
surgeon  will  therefore  consider  carefully  his  every  word  and  act 
realizing  their  lasting  importance  as  affecting  the  emotional  nature 
of  his  patient.  .Many  of  the  nervous  are  highly  suggestible,  a  weak- 
ness which,  however,  may  be  utilized  by  the  understanding  advisor 
to  help,  even  as  it  will  ever  remain  a  definite  menace  in  the  hands  of 
the  crude  or  thoughtless  operator.  Damaging  habits  of  feeling  fre- 
quently have  their  birth  in  the  experiences  connected  with  opera- 
tive or  postoperative  treatment.  Impatience  and  irritability  are 
energy  leaks  which  should  nol  be  allowed  t<>  go  on  unchecked  by 
earnest,  friendly  warning.     Irritability  is  apt  to  begel   irritability, 


RECONSTRUCTION    OF    THE   PATIENT  635 

so  the  surgeon  who  is  the  patient's  friend  will  never  react  in  kind 
to  such  an  atmosphere,  but  with  the  wise  word,  the  patient  word, 
will  show  the  temporary  sufferer  the  lasting  harm  he  is  doing  him- 
self by  allowing  such  an  attitude  to  become  habitual. 

A  more  difficult  type  of  patient  to  save  from  himself  is  the  one 
who  surrenders  to  a  morbid  sense  of  depression.  To  many  natures, 
to  surrender  is  much  easier  than  to  fight.  To  be  hopeless  requires  less 
effort  than  to  maintain  faith;  to  be  a  quitter  is  much  more  comfort- 
able than  to  manfully  play  the  game.  Every  worker  with  humanity 
feels  the  dead  weight  of  these  weakling  leaners,  and  a  certain 
amount  of  each  worker's  strength  must  be  given  to  help  them  drag 
their  faltering  footsteps  along  the  path  of  recovery.  And  it  is  a 
temptation  to  many,  otherwise  strong  and  eager  in  the  fulfillment 
of  the  duties  involved  in  a  noble  work,  to  dodge  these  depressing  na- 
tures, many  of  whom  are  pure  parasites,  perfectly  willing  to  sap  the 
vitality  and  energy  of  surgeon,  nurse,  and  family.  In  helping  this 
type  of  patient,  a  discriminating  separation  of  classes  is  as  essen- 
tial as  in  the  diagnosis  of  fractures.  Many  found  to  be  sufferers 
from  chronic  autointoxication,  depressed  by  their  own  poisons,  can 
be  healed  through  the  advice  given  in  the  earlier  pages  of  this  chap- 
ter. A  few  will  be  found  temperamentally  inadequate — cases  of 
mild  constitutional  inferiority.  More  are  mere  mendicant  sympathy 
cravers.  A  jollying  attitude  is  the  simplest  way  of  escape,  but  an 
unworthy  one.  The  physician  must  be  willing  today  to  counsel,  and 
to  make  clear  to  the  depressed  patient  how  absolutely  one's  atti- 
tude is  of  his  own  making ;  how  every  mortal  creates  his  own  inter- 
nal weather;  and  how  the  spirit  of  real  manhood  and  womanhood  is 
capable  of  converting  all  unworthy  moods  into  wholesome  ones. 

Fear  is  the  emotion  which  causes  the  great  mass  of  nervous  harm. 
Fear  manifests  itself  in  numberless  aspects ;  undue  apprehension 
attends  every  step  of  many  patients'  progress  through  a  surgical  ex- 
perience ;  and  fear,  as  expressed  through  hypochondriacal  ideas, 
lastingly  discounts  much  perfect  operative  work.  Many  recoveries 
which  would  otherwise  have  been  complete  are  alloyed  by  the  fear 
element  which  the  surgeon  has  carelessly  allowed  to  persist,  or 
recognizing,  has  failed  to  dislodge.  I  encounter  many  cases  who. 
three,  five,  or  even  ten  years  after  comparatively  simple  surgical 
treatment,  are  living  the  half -invalid  life  because  they  are  still  fol- 
lowing the  "Don'ts"  of  surgeon  or  nurse — prohibitions  as  to  exer- 
cise and  work  which  have  grown  into  incapacitating  phobias.  Many 
thousands  are  today  piteously  protecting  themselves  from  any  pro- 
ductive effort — from  even  sufficient  exercise  to  keep  themselves  de- 


636  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

cently  comfortable — because  of  their  ignorant  fear  of  tearing  loose 
some  structure  which  Avas  the  object  of  the  surgeon's  attention 
months  or  years  ago.  "A"  can  not  run  the  sewing  machine  fear- 
ing some  repaired  organ  will  be  torn  loose  from  its  moorings ; 
"B"  likewise,  can  not  sweep  or  stoop  to  dust;  hundreds  never  play 
tennis  or  ride  horseback  or  swim:  thousands  arc  still  guarding  their 
hypersensitive  scars  from  even  the  cleansing  friction  of  a  Turkish 
towel.  It  would  seem  that  the  surgeon  had  impressed  such  patients 
strongly  with  the  poor  quality  of  his  work.  And  too  frequently  it 
is  the  surgeon's  fault;  too  frequently  he  has  left  the  impression  that 
he  did  a  poor  job  of  mending.  For  instead  of  inspiring  his  patients 
to  an  early  strengthening  of  the  body  and  toughening  of  the  tissues 
through  adequate  use  and  thus  developing  that  high  grade  of  tissue 
quality  which  will  endure  and  benefit  by  exercise  and  even  strain. 
he  supports  and  protects,  and  even  prohibits  the  very  use  which  is 
Nature's  only  method  of  permanent  reconstruction. 

Many  patients  are  damaged  through  the  overs olieitude  of  their 
families.  In  the  absence  of  definite  instruction  to  the  contrary,  they 
return  home  to  be  coddled  and  shielded  and  warned.  Not  infre- 
quently members  of  the  family  suffer  vicariously  at  this  stage  even 
more  acutely  than  the  patient,  and  would  literally  protect  the  field 
of  operation  with  armor-plate,  were  this  possible.  The  true  sur- 
geon strives  to  do  his  work  in  a  way  which  will  leave  his  patient 
fit  for  better  living,  rather  than  unfitted  for  normal  life  But  through 
overcaution  many  continue  to  live  half  wrecks,  because  they  have 
not  had  specific,  helpful  directions  for  the  resumption  of  active 
exercise  to  reestablish  normal  lissiie  lone — the  quick  reward  of 
properly  fed  tissues  naturally  used.  A  few  words  of  definite  di- 
rection, better  if  written,  stating  (dearly  when  exercise  may  be  taken. 
what  should  be  done,  and  when  the  handicaps  attendanl  upon  the 
operation  may  be  absolutely  ignored  and  normal  1  i ^  i 1 1  ?_^-  resumed, 
will  save  many  a  neurotic  from  becoming  chronically  and  incapac- 
itatingly  hypnotized  by  surgery.  Were  proper  after-treatment  of 
surgical  conditions  as  carefully  ordered  as  the  preparatory  instruc- 
tions, many  half-failures  would  be  converted  into  thorough  suc- 
cesses, and  operations  that  semiinvalidi/.e  be  replaced  by  operations 
that  cure. 

The  surgical  experience  presents  another  and  a  graver  danger  to 
neurotic  patients  who.  as  a  class,  dread  pain  and  stand  it  poorly. 
Many  of  them  practically  refuse  to  endure  even  discomforl  without 
artificial  surcease,  and  the  physician's  temptation  is  a  strong  one  to 
write  the  order  which  will  bring  the  drug  comfort.     There  are  con- 


RECONSTRUCTION    OF    THE   PATIENT  637 

ditions,  indeed,  in  which  every  dictate  demands  the  relief  of  acute 
suffering,  but  the  neurotic's  capacity  for  suffering  is  frequently  so 
exaggerated  that  he  refuses  to  endure  even  minor  discomforts,  dis- 
comforts common  to  ordinary  experience  and  entirely  unrelated  to 
surgical  conditions.  From  these  are  recruited  many  who  have  be- 
come hopelessly  wretched  through  the  thoughtless  or  easy-going 
prescription  of  the  surgeon.  His  influence  is  a  potent  one.  If  he 
feels  it  necessary  for  the  patient  to  have  a  hypnotic  every  night  he 
remains  in  the  hospital,  why  not  the  hypnotic  at  home?  If  the 
hypodermic  needle  is  the  surgeon's  answer  to  a  digestive  disturb- 
ance, headache,  or  other  minor  complication  of  convalescence,  what 
better  treatment  for  like  conditions  away  from  the  hospital?  If  an 
hour  or  two  of  restlessness  is  to  be  placated  by  the  harmless  ( ?) 
bromide  mixture  while  under  the  surgeon's  care,  why  not  bromides 
for  restlessness  growing  out  of  home,  business,  or  imaginary  wor- 
ries? And  so  ignorance,  indifference,  or  selfishness  on  the  surgeon's 
part  has  started  many  a  poor  devil  toward  his  earthly  hell.  A  few 
words  of  wise  counsel  or  encouragement,  a  timely  lavage,  a  dose  of 
oil.  an  intelligent  alteration  of  diet  or  an  appeal  to  manhood  or  wom- 
anhood might  have  quickly  met  the  situation,  proved  a  lasting  edu- 
cative factor,  and  saved  unmerited  disaster.  Through  the  sedative 
danger  the  surgeon  may  make  or  mar  his  patient's  future. 

The  wise  surgeon  is  primarily  a  wise  man.  The  wise  surgeon  is 
a  teacher,  and  the  weeks  under  his  care  afford  an  opportunity  for 
reeducation  from  which  each  normal  patient  will  benefit.  He  be- 
lieves and  he  teaches  that  high  health  can  rarely  be  given  by  the 
knife  alone,  but  must  be  earned  by  righteous  living.  He  is  quick  to 
see  beyond  his  patient's  surgical  needs;  he  is  able  to  detect  the  un- 
derlying faulty  habits,  and  through  his  wisdom  disclose  to  the  pa- 
tient his  duty  to  attain  the  health  that  counts  and  the  strength  that 
endures.  And  the  reward  which  comes  to  such  a  surgeon  is  found 
in  his  increasing  power  to  inspire  those  to  whom  he  ministers  with 
a  determination  to  so  attain  that  living  becomes  a  joy. 

Our  forefathers  recognized  in  surgery  only  a  mutilating  art.  To- 
day, more  and  more  truly,  surgery  is  becoming  a  learned,  construc- 
tive, discriminating  science. 


CHAPTER  LIX 

POSTOPERATIVE  TREATMENT  IN  CHILDREN 
By  Willard  Bartlett  and  J.  B.  Carlisle,  St.  Louis.  Mo. 

It  is  the  purpose  of  the  writers  of  this  chapter  to  take  up  the 
after-treatment  of  the  most  common  conditions  that  come  to  the 
surgeon  or  practitioner  of  medicine  for  surgical  operations  or  mi- 
nor surgical  treatment,  also  to  consider  some  of  the  most  frequent 
complications  that  follow  along  with  such  after-treatment. 

After  the  infant  has  recovered  from  the  operation,  he  may  be 
placed  at  the  breast  for  regular  feedings.  If,  however,  he  will  not 
nurse,  he  may  he  force-fed  perferably  with  breast  milk  if  it  is 
available.  Following  operations  Cor  spina  bifida  it  is  important  to 
keep  the  infant  on  his  back  when  not  nursing.  This  may  be  ac- 
complished most  effectively  by  pinning  the  night  dress  to  the  mat- 
tress or  to  the  sheets.  Elsberg1  says  that  the  infant  may  be  allowed 
to  remain  on  his  back  following  the  operation  provided  thai  suit- 
able dressings  have  been  applied  to  prevenl  the  soiling  of  the  wound 
by  urine  or  fecal  material.     For  this  he  uses  a  collodion  dressing. 

Following  operations  on  harelip  as  a  rule  do  treatment  is  neces- 
sary unless  the  sutures  have  been  placed  in  too  tightly.  If  such  is 
the  case  a  si  rip  of  adhesive  from  cheek  to  cheek  will  probably  les- 
sen the  tension  sufficiently.  Here  again  when  this  operation  is  on 
a  young  infant  the  feeding  may  be  started  as  soon  ;is  possible,  either 
by  having  the  infant  nurse  or  by  force  Heeding.  V.  P.  Blair2  in  writ- 
ing of  the  Lane  and  the  Brophy  operations  for  congenital  palates  or 
lip  clef  is  s;iys  thai  these  operations  should  be  done  on  infants  as 
soon  after  birth  as  possible.  He  further  states  that  tin1  depressions 
line  to  the  loss  of  blood  can  lie  met  by  saline  by  rectum.  lie  gives 
these  infants  four  cubic  centimeters  of  castor  oil  and  six  hundredths 
of  paregoric  by  mouth  a  few  hours  after  the  operation  to  remove 
the  blood  swallowed  during  the  procedure.  The  infant  is  given 
water  by  mouth  as  soon  a--  ii  cries,  and  then  is  \'n\  when  this  will 
no  longer  satisfy.     Usually  these  infants  are  fed  four  to  six  hours 

after  1l peration.    If  human  milk  is  available,  it  should,  of  course, 

be  given,  but  if  no1  the  feeding  of  modified  milk  should  be  started 
as  -'hui  as  possible.  Blair  further  states  that  in  older  infants  some- 
times an   anodyne   is   necessary  during   the    firsl    forty-eighl    hours 

638 


POSTOPERATIVE    TREATMENT   IN    CHILDREN  639 

after  the  operation.  He  uses  morphine  or  paregoric  in  very  small 
doses  when  the  infant  can  not  be  quieted  by  the  nurse.  It  is  often 
well  to  spray  the  throat  of  the  infant  with  some  antiseptic  following 
the  operation.  He  uses  saline  for  this,  gently  spraying  with  it 
every  two  hours  during  the  day  and  at  the  feeding  times  at  night. 
He  states  also  that  the  site  of  the  operation  should  be  carefully 
watched,  and  should  signs  of  infection  appear,  the  part  should  be 
painted  with  a  10  per  cent  colloidal  silver  solution  after  each  ir- 
rigation with  the  saline.  To  children  with  congenital  palates  re- 
quiring plastic  operations  Blair  gives  liquids  and  solids  for  the 
first  ten  days  and  all  food  and  water  given  for  the  first  few  days 
is  sterile.  He  does  not  allow  these  patients  to  talk  for  ten  days, 
but  they  are  allowed  to  get  up  on  the  second  or  third  day  after  the 
operation  if  they  have  no  increased  temperature.  Various  anti- 
septic solutions  may  be  used  in  these  cases  as  irrigations.  Hemor- 
rhage sometimes  occurs  following  these  operations.  This  may  be 
controlled  by  the  use  of  astringents  or  by  packing  with  gauze.  In 
case  that  these  measures  are  not  effective,  then  the  patient  may 
be  anesthetized  and  the  bleeder  sought  and  ligated.  Sutures  as  a 
rule  may  be  removed  at  the  end  of  a  week. 

Intubation  when  done  entails  as  a  rule  but  little  after-treatment. 
Following  the  operation  the  infant  may  be  allowed  to  nurse,  but  if 
he  refuses,  force  feeding  may  be  used.  In  the  case  of  a  child 
liquids  and  semisolids  may  be  given.  Holt  and  Howland3  say 
that  older  children  often  experience  some  difficulty  in  taking  food, 
and  for  these  they  recommend  the  device  of  Casselberry;  namely, 
that  of  having  the  patient's  head  lower  than  his  body  while  he 
drinks.  Often  in  these  patients  the  taking  of  food  and  water  may 
cause  excessive  coughing.  In  these  cases  food  and  water  may  be 
given  by  a  nasal  tube  or  the  stomach  tube.  Dyspnea  may  be 
caused  by  the  child  swallowing  the  tube  or  the  tube  becoming 
filled  with  mucus.  The  examination  of  such  a  patient  should  first 
be  to  see  whether  the  tube  is  in  place.  An  intubation  tube  should 
be  cleansed  once  a  day  or  more  if  the  case  demands.  Holt  further 
suggests  that  should  the  tube  at  any  time  be  coughed  up,  it  should 
not  be  replaced  until  dyspnea  appears  again.  The  length  of  time 
that  the  child  should  wear  this  tube  is,  of  course,  variable  in  dif- 
ferent cases.  Usually  extubation  is  done  when  the  child's  tempera- 
ture reaches  normal. 

The  removal  of  tuberculous  glands  in  children  requires  little  local 
after-treatment  except  in  keeping  the  wound  free  from  secondary 
infection.     The  general  treatment  is  usually  of  much  more  value, 


6-10  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

tending  to  build  the  child's  condition  up  with  tonics,  fresh  air,  good 
food,  and  good  hygiene  in  general. 

Furunculosis  which  so  frequently  occurs  in  children  can  best  be 
treated  by  stock  vaccines  of  the  staphylococcus  or  by  an  autogenous 
vaccine  if  such  are  available.  General  tonics  are  sometimes  of  value 
for  the  accompanying  digestive  disorders.  Yeast  may  be  used  in 
some  cases  as  reported  by  Hawk  with  benefit.  As  a  rule,  however, 
autogenous  vaccines  are  of  more  value.  Distant  reinfections  are 
best  prevented  by  frequent  cleansing  of  the  patient's  fingers  with 
alcohol. 

Following  the  removal  of  tonsils  and  adenoids  primary  or  sec- 
ondary hemorrhage  may  occur.  Primary  hemorrhage  is  usually 
very  slighl  and  can  be  controlled  with  certain  astringents  such  as 
adrenalin  or  hydrogen  peroxide  or  by  the  use  of  pressure  or  packs. 
Secondary  hemorrhage  is  usually  more  severe,  sometimes  becoming 
so  severe  as  to  require  suturing  as  described  by  Coolidge.4  This 
method  consists,  after  the  patient  is  etherized,  in  passing  a  curved 
needle  from  behind  forward  through  the  posterior  pillar,  the  con- 
strictor muscle,  and  the  anterior  pillar.  These  three  sutures  thus 
placed  will  obliterate  the  space  of  the  removed  tonsil  and  are  ef- 
fective in  stopping  the  bleeding.  The  sutures  may  then  lie  removed 
in  three  or  four  days  unless  catgut  has  been  used.  Some  cases  of 
secondary  hemorrhage  developing  three  or  four  hours  after  the 
operation  or  the  next  day  may  lie  stopped  by  simple  packing  and 
by  ligation  of  the  vessel  when  it  can  be  seen.  Hemorrhage  following 
removal  of  adenoids  may  usually  be  controlled  by  packing. 

In  children  who  have  long  been  accustomed  to  breathing  through 
their  months  it  may  be  necessary  to  apply  a  bandage  to  force  them 
to  breathe  through  the  nose  until  they  have  become  accustomed  to 
it.  As  a  rule,  following  removal  of  tonsils  and  adenoids  it  is  well 
to  have  the  patients,  especially  young  children,  stay  in  lied  a  day  or 
two  during  which  time  they  should  he  carefully  watched  for  the 
development  of  secondary  hemorrhage.  The  diet  during  this  time 
should  be  a  lighl  one.  It  is  also  well  to  spray  the  throat  with  some 
mild  antiseptic  solution  for  several  days  after  the  operation.  If 
they  have  no  increased  temperature  at  the  end  of  the  second  day. 
they  may  be  allowed  to  get  up. 

The  postoperative  treatment  in  empyema  is  a  very  important  one 
1, .■cause  empyema  itself  may  complicate  any  of  the  infectious  dis- 
eases that  are  so  common  in  children.  It  may  also  come  as  the  resull 
of  trauma.  The  opening  of  the  thorax  may  be  followed  by  drainage 
in  a  number  of  ways.    Perhaps  the  method  of  Kinyon  spoken  of  by 


POSTOPERATIVE    TREATMENT    IX    CHILDREN  641 

Holt3  is  as  good  a  one  as  any.  This  method  consists  of  a  siphon 
drainage  into  a  bottle  containing  saline.  In  those  cases  that  he 
terms  "desperately  sick"  Wyman  Whittemore5  advised  a  somewhat 
different  treatment :  ' '  Under  local  anesthesia  the  chest  is  aspirated 
between  the  ribs  with  a  large  trocar;  a  tight-fitting  catheter  slipped 
through  this  and  the  trocar  removed.  The  catheter  is  attached  to 
a  long  rubber  tube  that  goes  to  a  bottle  half  filled  with  water.  The 
end  of  the  tube  is  under  the  surface  of  the  water.  The  catheter  is 
screwed  tightly  into  place.  In  this  way  the  negative  pressure  of  the 
pleural  cavity  is  not  changed  and  with  each  expansion  of  the  lung 
the  pus  is  forced  into  the  bottle.  The  catheter  will  stay  tight  with- 
in the  chest  wall  for  about  a  week.  The  amount  of  drainage  for 
each  twenty-four  hours  is  measured.  At  the  end  of  five  or  six  days 
an  electric  suction  is  attached  to  the  tube.  This  works  constantly, 
and  when  the  twenty-four  hour  amount  of  pus  is  down  to  two 
ounces,  I  remove  all  drainage  apparatus.  In  those  cases  not  quite 
so  severe  the  Lilienthal  operation  is  used. ' '  The  postoperative  treat- 
ment in  both  of  these  cases  is  practically  the  same.  G-ood  food, 
fresh  air,  regular  breathing  exercises  are  to  be  insisted  upon  and 
also  the  "blow  bottles"  in  some  cases.  Whittemore  does  not  think 
that  bottles  are  of  much  value. 

In  some  cases  in  which  the  drainage  of  the  cavity  is  insufficient  it 
is  sometimes  necessary  to  irrigate.  These  irrigations  may  be  done 
with  saline,  but  more  recently  many  are  doing  them  by  using  the 
Carrel-Dakin  solution.  It  is  the  practice  at  the  St.  Louis  Children's 
Hospital  to  use  the  Wilson  tube  in  drainage  and  in  those  cases 
which  require  irrigation  Carrel-Dakin  solution  is  used  in  small 
amounts  at  frequent  intervals.  The  general  after-treatment  in  all 
cases  is  essentially  the  giving  of  good  food,  plenty  of  time  out  of  doors 
in  suitable  weather,  and  the  forced  expansion  of  the  lung.  James y 
apparatus  which  is  a  blowing  device  of  two  bottles  is  sometimes 
very  effective  in  expanding  them. 

Frequently  the  temperature  will  again  rise  following  insufficient 
drainage  of  the  cavity,  due  to  a  developing  pneumonia,  to  empyema 
of  the  opposite  side,  to  pericarditis,  or  to  otitis.  All  of  these  condi- 
tions must  be  carefully  watched  for  and  treated  early  if  they  appear. 
In  the  chronic  cases  of  empyema  practically  all  the  treatment  that 
is  necessary  is  to  keep  the  wound  as  clean  as  possible,  promote  ade- 
quate drainage,  and  in  general  attempt  to  increase  the  resistance 
of  the  patient.  Beck's  paste  may  be  used  in  these  cases.  It  is  well 
to  remember  that  in  the  acute  cases  a  drainage  tube  left  in  too  long 
will  often  lead  to  a  fistula. 


642  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

Stricture  of  the  esophagus  in  children  is  not  uncommonly  seen 
due  to  lye  or  other  powerful  caustics.  Such  cases  as  these  are  often 
not  seen  by  the  surgeon  until  late  after  the  swallowing  of  such  ma- 
terials. The  starvation  and  the  extreme  water  hunger  in  these 
cases  when  seen  often  demand  an  immediate  gastrostomy  as  pointed 
out  by  Hubbard.0  Following  such  a  treatment  the  surgeon  should 
attempt  to  pass  I  possibly  retrograde)  whalebone  filiforms  or  the 
smallest  bougies  as  soon  as  possible.  Certain  of  these  cases  can 
have  tin'  esophagus  after  a  long  and  tedious  process,  dilated  to  a 
point  where  after  several  days  the  gastrostomy  wound  may  be 
closed  and  the  feeding  by  mouth  resumed.  These  patients  should 
return  to  the  surgeon  for  regular  dilatations  of  the  esophagus.  In 
the  case  of  the  child,  this  point  must  be  thoroughly  impressed  upon 
the  parents  so  that  not  one  of  these  dilatations  shall  be  missed. 
Another  point  which  is  of  equal  importance  and  was  brought  ou1 
in  the  article  referred  to  above  is  that  these  patients  are  often  for 
a  long  time  fed  upon  liquids  and  semisolids  which  do  not  furnish 
sufficient  nourishment  and  lead  to  malnutrition  and  lack  of  proper 
development.  They,  he  say'-,  may  be  allowed  to  eat  all  kinds  of 
foods  if  they  are  taughl  to  masticate  well  what  they  do  eat.  In 
certain  cases  where  the  stricture  of  the  esophagus  is  of  such  a 
nature  that  the  bougie  or  the  small  whalebone  filiforms  can  not  be 
passed  from  above  an  attempt  may  be  made  to  have  the  child  swal- 
low a  string  and  if  successful  then  the  dilatation  can  be  attempted 
from  below  through  the  gastrostomy  wound. 

The  postoperative  treatment  of  pyloric  si  miosis  in  children  is  a 
very  important  one.  and  one  about  which  a  great  deal  has  been 
written.  [Most  writers,  however,  are  agreed  upon  one  point,  and 
that  is  that  the  postoperative  treatment  is  usually  of  as  much  im- 
portance as  the  operative  treatment  itself.  For  this  condition  in 
infants  there  are  two  methods  of  after-treatment  which  are  very 
different.  Green  and  Silbury7  write  of  the  after-treatment  follow- 
ing the  Rammstedl  operation  as  follows:  "The  infant  must  have 
breast  milk  in  small  quantities,  gradually  increased.  The  method 
of  the  Babies'  Hospital  in  New  York  is  followed.  The  feeding 
is  started  two  hours  after  the  operation,  or  when  the  baby  is 
awake  from  the  anesthetic,  with  four  cubic  centimeters  of  breast 
milk  and  the  same  amount  of  barley  water  every  three  hours,  in- 
creasing by  four  cubic  centimeters  of  breast  milk  every  other 
feeding  until  we  get  the  breast  milk  up  to  thirty  cubic  cen- 
timeters and  then  we  give  thirty  cubic  centimeters  of  breast 
milk  every  four  hours  during  the  da\    and  at   night.     The  baby  is 


POSTOPERATIVE    TREATMENT    IN    CHILDREN  643 

not  allowed  to  nurse  the  mother  for  from  five  to  seven  days  after 
the  operation,  and  when  it  does,  is  weighed  before  and  after 
each  feeding  to  determine  the  amount  obtained.  Castor  oil 
is  given  twenty-four  hours  after  the  operation.  Practically  every 
case  that  we  have  treated  has  received  an  anteoperative  hypoder- 
moclysis  and  some  few  have  received  it  after  the  operation.  The 
greatest  care  must  be  taken  not  to  chill  the  infant  during  the  opera- 
tion, and  after  it  external  heat  should  be  applied."  In  general  the 
cooperation  of  the  surgeon  and  the  pediatrist  is  required  in  these 
cases  to  insure  success.  Thompson8  says  "that  shock  and  hemor- 
rhage must  be  avoided  after  the  operation  and  that  shock  may  be 
combated  with  warm  saline  infusions  or  transfusions  and  by  mild 
stimulations  if  necessary.  Rectal  feeding  or  saline  enemata  may 
he  employed  for  a  few  hours  or  longer.  Food  per  orem  can  be  ad- 
ministered in  a  few  hours  or  the  next  day  and  this  is  often  necessary 
on  account  of  the  precarious  condition  of  the  child  and  its  impera- 
tive need  for  nourishment."  Morse  and  Cabot9  also  recommend 
postoperative  salt  enemata.  They  say  that  feeding  may  be  begun 
in  the  child  as  soon  as  the  effects  of  the  anesthetic  are  passed.  They 
recommend  human  milk  diluted  with  three  parts  of  water,  the 
strength  being  gradually  increased,  but  if  breast  milk  can  not  be 
obtained,  then  whey  is  the  next  best  gradually  to  be  strengthened 
by  gravity  cream  to  1  per  cent  of  fat.  They  consider  it  best  to  feed 
one  dram  every  hour,  increasing  the  amount  and  lengthening  the 
interval  between  the  feeding. 

Most  surgeons  now  have  adopted  the  Rammstedt  operation  in 
preference  to  the  older  gastroenterostomy  which  is  attended  by  a 
higher  mortality,  more  shock,  and  a  slower  convalescence.  In  a 
case  where  a  gastroenterostomy  is  done  the  infant  can  not  be  fed 
as  soon  after  the  operation  and  the  feeding  in  general  must 
be  more  cautiously  carried  out  than  in  the  case  of  the  infant 
upon  whom  the  Rammstedt  operation  has  been  done.  Holt  and 
Howland10  recommend  another  treatment.  The  infant  is  given  one 
or  two  teaspoonsful  of  breast  milk  every  two  hours  alternating  with 
the  same  amount  of  water.  The  amount  is  gradually  increased  and 
the  interval  is  lengthened  until  at  the  end  of  forty-eight  hours  the 
infant  is  getting  an  ounce  of  milk  every  three  hours  and  the  same 
amount  of  water  between  the  feedings.  At  the  end  of  a  week  or 
ten  days  the  infant  may  be  put  back  to  the  breast  and  allowed  to 
nurse,  but  care  should  be  taken  that  it  does  not  nurse  too  long  or 
does  not  get  too  much  at  any  one  feeding.  Holt  further  states  that 
hypodermoclysis  is  of  value  at  the  beginning  of  the  operation  and 


611  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

after  it.  In  these  eases  100  to  240  c.c.  of  saline,  to  which  3  per 
cent  of  glucose  has  been  added  may  be  given  to  relieve  the  lack  of 
water.  The  importance  of  the  after-treatment  in  these  cases  can 
not  be  overestimated.  With  an  early  recognition  of  the  condition, 
a  Rammstedt  operation  in  the  hands  of  a  good  surgeon,  and  then 
careful  treatment  afterwards  by  an  experienced  pediatrist  the 
chances  for  the  infant's  recovery  ought  to  be  very  good. 

Umbilical  hernia  rarely  occurs  in  children  under  four  that  is  not 
amenable  to  mechanical  rather  than  surgical  treatment.  If,  how- 
ever, this  treatment  will  not  suffice,  and  the  child  has  to  under- 
go an  operation,  then  the  after-treatment  consists  in  meeting 
hemorrhage,  should  it  occur,  or  shock,  and  the  feeding  of  the  infant. 
Shock  may  be  treated  with  saline  and  glucose  solutions.  The  treat- 
ment of  hemorrhage  is  the  same  as  that  for  hemorrhage  in 
other  abdominal  conditions.  The  feeding  may  be  begun  as  soon 
as  the  child  is  over  the  operation,  the  nature  of  the  feeding  and 
the  times  for  it  depending  on  the  age  of  the  patient.  Very  strenu- 
ous efforts  at  play  must  be  avoided  for  a  few  weeks  after  he  is  up 
at  the  end  of  ten  days.  The  prognosis  is  one  hundred  per  cent 
good. 

Intestinal  obstructions  due  to  malformations  of  the  intestines  are 
sometimes  seen  in  the  newborn  due  to  atresia  or  absence  of  the 
rectum,  colon,  or  anus.  The  mortality  in  these  cases  is  usually  very 
high  due  to  the  late  period  at  which  they  are  recognized  or  to  the 
marasmus  existing  at  that  time.  Should  an  operation  be  done  on 
these  infants,  the  after-treatment  will  depend  a  great  deal  on  the 
nature  and  the  extent  of  it.  but  in  general  it  will  be  the  same 
as  that  following  an  operation  for  an  umbilical  hernia.  The 
after-treatment  in  cases  of  obstruction  following  intussuscep- 
tion is  very  important,  but  as  a  rule  presents  nothing  different  from 
that  accorded  obstruction  due  to  malformation.  Lack  of  water  is 
often  of  very  grave  importance  in  these  conditions.  This  can  be 
combated  by  giving  water,  saline  or  saline  and  glucose  if  preferred, 
subeutaneously.  intravenously  or  into  the  peritoneal  cavity.  This 
last  method  is  the  one  employed  at  the  St.  Louis  Children's  Hospital 
in  eases  of  anhydremia  with  good  results. 

Although  appendicitis  is  a  disease  usually  seen  in  adults,  it  may 
be  seen  in  infancy  and  is  frequently  seen  in  children.  The  after- 
treatment  in  such  cases  occurring  in  children  is  much  the  same  as 
that  in  adults.  Those  general  principles  outlined  by  Ochsner," 
may  be  followed.  In  his  uncomplicated  cases  in  which  drainage 
has  not  been  used  the  patients   are   given  no  food  by  mouth  for 


POSTOPERATIVE    TREATMENT    IN    CHILDREN  645 

three  to  seven  days  according  to  the  conditions.  Gastric  lavage  is  em- 
ployed in  patients  who  are  nauseated,  nutrition  being  supplied  to 
these  patients  by  rectum.  Solid  foods  are  not  usually  given  until  two 
weeks  after  the  operation.  The  stitches  are  removed  on  the  tenth 
to  the  fifteenth  day  and  then  adhesive  is  placed  over  the  wound 
for  support.  In  those  cases  demanding  drainage  boric  acid  dressings 
are  used.  As  a  rule  in  the  uncomplicated  cases  patients  are  kept  in 
bed  two  weeks.  A  resulting  ventral  hernia  in  children  is  so  rare 
that  it  hardly  deserves  mention  in  this  treatise. 

In  general  the  temperature  in  these  cases  of  appendicitis  in  chil- 
dren should  be  carefully  watched,  and  should  any  sign  of  peri- 
tonitis develop,  all  feeding  by  mouth  should  be  stopped  if  it  has 
been  started.  The  lesion  may  then  be  treated  as  is  done  in  adults 
with  hypodermoclysis,  morphine,  etc. 

Renal  calculi  are  very  common  in  infancy  according  to  Holt  and 
Howland.12  The  postoperative  treatment  in  these  cases  depends 
on  the  type  of  operation  that  is  done.  If  the  pelvis  is  opened  and 
the  calculi  removed,  the  after-treatment  will  be  simple  unless 
hemorrhage  or  a  urinary  fistula  develops.  A  urinary  fistula  would 
demand  a  second  operation  if  possible.  The  feeding  of  these  in- 
fants, like  the  feeding  of  infants  following  the  Eammstedt  opera- 
tion, is  sometimes  very  important.  The  general  measures  to  be 
followed  in  such  a  feeding  are  to  give  breast  milk  if  possible  in 
small  doses,  increasing  the  amounts  and  finally  when  possible  the 
return  of  the  child  to  the  breast.  Water  hunger  if  it  occurs  fol- 
lowing the  operation  can  be  relieved  by  saline  infusions.  Os- 
teomyelitis is  so  fully  considered  in  the  chapter  "Surgery  of  the 
Extremities"  that  it  will  be  omitted  here.  It  can  occur  in  infants, 
but  more  frequently  is  seen  in  children. 

Scuclder13  says  that  fully  one-third  of  the  fractures  of  the  clavicle 
occur  in  children  under  five  years  of  age.  The  treatment  in  these 
cases  after  the  deformity  is  corrected  lies  in  the  immobilization  of 
the  part  for  two  weeks  or  more.  The  arm  should  be  inspected 
especially  in  warm  weather  to  see  that  no  chafing  of  the  part  oc- 
curs. All  the  dressings  should  be  daily  removed,  the  parts  bathed 
with  soap  and  water,  powdered  and  the  dressings  replaced.  If  the 
union  is  firm  after  two  weeks  or  two  weeks  and  a  half,  the  cast 
may  be  removed  and  the  shoulder  can  then  be  put  up  in  a  simple 
retentive  swathe  and  sling,  at  first  inside  the  clothes  and  later 
outside  them.  Massage  may  be  given  to  the  forearm,  elbow,  and 
shoulder  after  the  first  week  together  with  passive  motion  of  the 
elbow.    If  the  dressing  chafes  or  slips,  it  may  need  frequent  renewal. 


646  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

Fracture  of  the  shaft  of  the  humerus  sometimes  occurs  in  the 
newborn  and  has  for  its  after-treatment  the  same  principles  as 
outlined  above  for  fractures  of  the  clavicle.  Scudder  treats  the 
fractures  of  the  femur  in  the  newborn  by  flexing  the  leg  upon  the 
body.  The  after-treatment  in  these  cases  consists  in  the  daily 
massage  of  the  leg  and  the  preventing  of  the  parts  from  chafing. 

In  general,  fractures  in  infancy  are  uncommon  but  they  are  rather 
common  in  children.  The  general  treatment  in  all  cases  is  the 
protection  of  the  skin  and  the  proper  immobilization  of  the  part 
to  insure  correct  healing  of  the  fracture.  As  a  routine  it  is  well 
to  take  a  second  x-ray  picture  of  the  fracture  after  ten  days  or  two 
weeks  to  see  whether  or  not  the  bones  are  properly  approximated. 

Burns,  when  seen  in  children,  are  most  commonly  those  of  the 
extremities.  The  use  of  paraffin  dressings  or  the  dry  heat  treat- 
ment is  used  in  most  hospitals  now.  This  heat  may  be  applied 
by  means  of  a  tent  over  the  extremity  which  has  an  electric  light 
bulb  on  the  inside.  When  crusts  form  on  these  burns  they  should 
be  removed  and  a  dressing  of  scarlet  red  applied.  In  the  case  of 
the  more  serious  lesions  a  Thiersch  graft  may  be  applied.  As  in  the 
case  of  adults  it  is  also  necessary  to  produce  proper  elimination  of 
the  toxins  of  a  severe  burn  through  the  kidneys,  skin,  and  the 
bowels. 

Full  credit  is  due  J.  B.  Carlisle  for  having  abstracted  all  the  lit- 
erature to  which  reference  is  made  in  this  chapter. 

Bibliography 

lElsberg:     Diseases  of  the  Spinal  Cord  and  Membranes,  1916,  p.  187. 

sBlair,  V.  P.:     Surgery  of  the  Mouth  and  .laws.  St.  Louis,  1917,  C.  V.  Mosby  Co., 

ed.  3,  pp.   195-215. 
■Holt   and   Howland:      Diseases   of    Infancy   and    Childhood,   New   York.    1917, 

D.  Appleton  &  Co.,  ed.  7.  pp.  1055-1057. 
■*Coolidge:     Diseases  of  the  Nose  and  Throat,  Philadelphia,  191.1,  W.  B.  Saun- 
ders Co.,  pp.   205-206. 
5Whittemore,  Wyman:     P>oston  Med.  and  Surg.  Join-.,  1918,  elxxviii,  360. 
cHubbard:     Section   on   Laryngology,    Otology,   and   Ehinology,    Tr.    Am.    Med. 

Assn.,  Chicago,  June,  1918,  p.   31. 
"Green  and  Silbury:     Hypertrophic  Stenosis  of  the  Pvlorus,  Surg.,  Gvnec.  and 

Obst.,  February.  1919,  p.  159. 
sThompson:     Congenital  Hypertrophic  Stenosis  of  the  Pvlorus  in  Infants,  Surg., 

Gynec.  and  Obst.,  1906,  iii,  521. 
oMorse  ami   Cabot:      Hypertrophic   Stenosis  of  the  Pylorus  in  Diseases  of  Nu- 
trition and  Feeding,  p.  217. 
loHolt  and  Howland:      Diseases  of  Infancy  and   Childhood,   New  York,   1917,  D. 

Appleton  &  Co.,  ed.  7.  p.  328. 
nOchsner:     Handbook  of   Appendicitis,    1902,   Chicago,  G.  P.  Engelhard  &  Co. 
isHolt  and  Howland:     Loc.  fit.,  p.  646. 
i'S,.„ilder:     The  Treatment  of  Fractures,  1911. 


CHAPTER  LX 

POSTOPERATIVE  TREATMENT  IN  OLD  AGE 
By  Willard  Bartlett  and  C.  R.  Fancher,  St.  Louis,  Mo. 

Before  considering  postoperative  treatment  in  old  age,  it  would 
be  well  to  consider  that  every  old  person  has  a  definite  and  more 
or  less  constant  pathology.  Certain  modifications  at  once  arrest 
your  attention.  Every  one  is  familiar  with  the  appearance  of  an 
old  man  or  woman.  We  find  as  we  look  at  an  elderly  individual,  a 
great  change  has  come  over  the  face.  The  roundness  of  youth 
has  departed;  the  cheeks  are  shrunk;  the  eyes  have  receded;  the 
lips  are  drawn  in.  The  gait  becomes  shuffling;  the  foot  is  no  longer 
lifted  free  from  the  ground  as  the  aged  individual  walks  along. 

The  skin  becomes  thin  and  satiny,  while  disappearance  of  fat 
and  muscle  tissue  beneath  it  throws  it  into  wrinkles,  the  hair 
after  becoming  white  falls  out,  the  muscles  waste  away  and  grow 
weak;  and  the  ligaments  which  bind  together  the  bones  stretch  and 
weaken.  Deprived  of  its  strong  muscular  and  ligamentous  sup- 
port, the  back  bends  forward,  the  bones  become  rarefied  and  the 
cartilaginous  structures  become  ossified.  The  bones  break  more 
easily  and  heal  with  greater  difficulty  than  in  a  young  person, 
all  of  which  correspond  to  a  general  atrophy  of  the  individual, 
for,  at  the  same  time  stature  diminishes  and  the  weight  of  the  body 
generally  decreases.  This  emaciation  is  the  consequence  of  a  morbid 
process  which  exerts  its  action  upon  the  muscles  of  organic  life 
and  upon  the  greater  number  of  the  organs,  e.  g.,  the  brain,  spinal 
cord,  nerve  trunks,  lungs,  cardiovascular  system,  kidneys,  and  blood- 
forming  organs  all  participate  in  this  retrograde  process. 

Of  what  does  this  change  in  the  collective  organs  and  tissues  con- 
sist? 

First :  In  the  slightest  degree,  it  is  a  simple  process  of  atrophy, 
the  cellular  elements  of  the  parenchyma,  the  muscular,  and  perhaps 
also  the  nervous  tissues,  progressively  diminish  in  volume,  but 
without  any  demonstrable  change  in  structure.  But  in  a  more  ad- 
vanced stage  atrophy  is  accompanied  by  degenerative  action ;  i.  e., 
the  tissues  undergo  a  modification  in  their  anatomic  and  physiologic 
activities,  and  we  find  that  they  are  the  seat  of  pigmentary,  also 
fatty  degenerations,  and  calcareous  incrustations. 

G47 


648  AFTER-TREATMEXT    OP    SURGICAL    PATIENTS 

No  one  will  fail  to  observe  that  if  these  changes  have  attained 
a  pronounced  degree,  they  will  go  beyond  the  limit  of  the  physi- 
ologic state,  since  they  have  the  power  to  produce  of  themselves. 
functional  derangements  which  at  times  are  extremely  grave.  The 
generative  and  muscular  systems  undergo  so  evident  an  enfeeble- 
ment  that  it  is  not  necessary  to  dwell  upon  this  point,  and  with 
regard  to  the  nervous  system  of  organic  life  it  is  veil  to  recall 
the  well-known  lines  of  Lucretius.  "Praeterera  gigni  pariter  cum 
corpore.  et  una  crescere  sentimus,  pariterque  senescere  mentem" — 
De  Nat.  lucrum,  ii,  446. 

Mental  changes  may  manifest  themselves  as  a  senile  dementia, 
confusion,  mania,  melancholia,  or  as  a  senile  "paranoia."  This  is 
of  considerable  importance  in  considering  the  various  mental  condi- 
tions, the  whims  and  fancies  which  sick  old  people  are  liable  to 
have. 

The  functions  of  the  respiratory  apparatus  are  as  a  whole  trener- 
ally  decreased.  This  will  be  evident  when  Ave  consider  for  a  moment 
the  pathology  of  the  senile  lung  and  thoracic  cavity.  The  senile 
lung  is  emphysematous.  The  Avails  of  the  arteries  are  inelastic, 
large  numbers  of  capillary  vessels  have  been  obliterated  and  in- 
termixed throughout  the  en  lire  structure  there  is  always  found 
a  diffusion  of  carbonaceous  material.  The  senile  lungs  can  not  be 
perfectly  inflated,  and  present  a  livid  appearance.  Thin  surfaces 
are  uneven  and  look  as  though  they  were  crumpled.  Not  only  do 
the  previously  mentioned  factors  decrease  the  respiratory  func- 
tions, but  also  the  musculature  of  the  chesl  becomes  atrophic:  the 
costal  cartilages  become  ossified,  all  of  which  prevent  or  hinder 
the  complete  filling  of  the  lungs.  Many  investigators  think  that 
these  changes  begin  as  early  as  the  thirty-fifth  year  and  reach  a 
maximum  about  the  seventy-fifth  year. 

The  cardiovascular  system  is  profoundly  involved  in  senility.  The 
heart,  like  every  other  organ  in  the  body,  undergoes  atrophy  and 
sIioavs  various  degenerative  changes  which  directly  lead  to  an  in- 
efficient organ.  The  heart  usually  becomes  small  and  brown  with 
tortuous  coronary  arteries,  which  are  visible  through  the  watery, 
broAvnish  fat.  The  fat  of  the  epicardium  usually  disappears  and 
its  cells  become  separated  by  a  fluid  which  gives  a  gelatinous  ap- 
pearance to  the  tissue.  The  decrease  in  the  size  of  the  heart  makes 
it  too  small  for  the  coronary  vessels,  which,  therefore,  lake  the 
tortuous  course  above  mentioned.  Each  heart  muscle  cell  is  greatly 
reduced   in   size,   and   there   show  at   tin1   poles   of  the   nuclei   certain 


POSTOPERATIVE  TREATMENT  IN  OLD  AGE  649 

brown  pigmentations  which  constitute  the  so-called  "brown  atro- 
phy" of  the  myocardium. 

Besides  the  senile  changes  that  take  place  in  the  heart,  the  very 
important  sclerotic  changes  that  take  place  in  the  vessels  are  of 
next  importance ;  the  effects  of  this  sclerotic  change  causing,  of 
course,  an  abnormal  vascular  wall,  which  is  inelastic  and  gradually 
encroaches  on  the  vascular  lumen.  This  decrease  in  cross  section 
of  the  vessels  causes  a  decrease  in  the  quantity  of  blood  brought 
to  any  given  organ;  also  causes  an  increase  in  the  amount  of  cardiac 
work  clue  to  the  increased  peripheral  resistance. 

The  kidneys  are  affected  in  senility,  the  change  usually  found 
being  the  so-called  "arteriosclerotic  kidney,"  in  which  the  organ 
is  contracted,  and  the  thickened  capsule  generally  adherent.  On 
section  the  kidney  shows  macroscopically  certain  localized  areas  of 
atrophy.  There  is  a  disappearance  of  the  pelvic  fat,  and  a  marked 
decrease  in  the  cortical  and  pyramidal  portions.1  In  the  senile 
kidney  the  urine  is  generally  decreased.  The  urine  analysis  shows 
hyaline  and  granular  casts  and  usually  a  trace  of  albumin.  The 
amount  of  albumin  varies  greatly  with  the  food  and  the  amount  of 
exercise  taken.  Casts  may  occur  without  the  albumin.  It  is  not  to 
be  regarded  as  a  grave  sign  to  find  any  of  the  above  in  a  senile 
individual. 

The  liver  in  senility  shows  a  flabby,  shrunken  organ  usually  of  a 
dark  color  made  up  of  lobules  far  smaller  than  normal;  often  whole 
layers  of  liver  tissue  disappear ;  so  that  on  the  surface  of  the  organ, 
blood  vessels,  bile  ducts,  and  the  fibrous  skeleton  of  the  liver  lie 
exposed.  All  of  these  senile  changes  must  play  a  very  important, 
yet  comparatively  unknown,  part  in  the  metabolism  of  the  indi- 
vidual, also  on  the  metabolic  changes  going  on  in  the  liver  itself. 
The  liver  is  known  to  have  something  to  do  with  the  metabolism 
of  the  more  complex  amino  acids,  and  it  is  conceivable  that  a  per- 
verted liver  metabolism  might  have  something  to  do  with  the  pig- 
mentations which  are  so  common  in  aged  individuals,  due  of  course, 
to  the  incompletely  broken-up  amino  acids  which  contain  color  groups. 
The  skin  is  affected  more  than  any  other  single  organ  in  senility. 
It,  like  any  other  organ,  undergoes  definite  changes ;  since  it  is 
dependent  on  other  systems  of  the  body  for  its  well  being,  and  in 
order  to  maintain  its  equilibrium,  i.  e.,  chemical  and  physical,  must- 
have  the  proper  food  and  environment.  The  senile  skin  shows 
very  important  changes  which  really  mark  the  beginning  of  the 
end.     The  causes  are  not  known,  but  they  usually  start  in  the  ves- 


650  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

sels  of  the  true  skin.  This  decreased  nutrition  allows  infection, 
causes  itching-  and  gangrene;  There  are  also  changes  in  the  con- 
nective tissues;  there  is  an  atrophy  without  adequate  repair,  in- 
stability and  irritability  of  the  epidermal  cells,  which  have  a  ten- 
dency to  a  typical  and  rapid  transformation.  Therefore,  we  find 
pigmented  plaques  and  warts  which,  along  with  the  previously  men- 
tioned factors,  predispose  to  carcinomata,  hence  they  are  poten- 
tially cancers.  Sir  James -Paget  once  said,  "If  we  live  long  enough, 
we  will  all  die  of  cancer,"  and  from  senile  skin  findings  this  is  quite 
true.  Most  dermatologists  are  agreed  that  senility  of  the  skin 
does  not  mean  in  all  cases  age  in  years,  bu1  skin  changes  are  some- 
times due  to  processes  not  well  understood.  Senile  skin  changes  are 
usually  first  noticed  on  the  dorsum  of  the  hands  and  the  sides  of 
the  neck.  One  of  the  most  striking  alterations  in  the  skin  of  an 
old  individual  is  the  lack  of  repair.  The  slightest  amount  of  trauma 
very  frequently  will  cause  a  very  severe  dermatitis  or  an  ulcer. 

From  what  has  been  said  it  is  quite  evident  that  old  age  is  es- 
sentially a  period  of  involution,  of  diminished  power  for  sus- 
tained expenditure  of  energy,  and,  commonly,  of  a  lessening  in 
the  general  range  of  activities.  The  organism  begins  to  reveal 
gradual  and  increasing  changes  in  its  structure,  all  of  which  are 
expressive  of  senescence.-  Noticeably  is  this  the  case  of  the  cardio- 
vascular system.  The  heart  no  longer  has  the  power  to  drive  the 
blood  with  its  former  energy,  while  the  vessels  present  walls  no 
longer  soft  and  yielding,  but  now  rigid  and  with  a  narrowed  lumen. 
The  changes  of  function  that  ensue,  are,  however,  in  a  vast  majority 
of  mankind,  entirely  normal  and  in  no  sense  pathologic.  There  is  a 
quantitative  reduction,  but  this  is  usually  limited  in  degree  so  that 
the  individual  may  continue  to  discharge  his  functions  normally  to 
the  end  of  life.  It  is  only  when  this  reduction  is  excessive,  and  espe- 
cially when  it  is  associated  with  qualitative  changes,  that  it  be- 
comes pathologic. 

The  surgical  after-treatment  in  the  aged  does  not  differ  in  the 
main  from  the  postoperative  treatment  of  adults.  In  the  first  place, 
age  is  a  contraindication  to  operations  of  the  more  serious  nature. 

Old  individuals  can  not  stand  shock;  their  fighting  powers,  one 
might  say.  are  far  Prom  what  you  would  expect  in  an  adult.  Some 
of  the  more  salient  points  to  be  considered  in  the  after-treatment 
are  as  follows : 

1.  During  the  operation  and  after  the  operation  the  patient  should 
be  kept  warm.    This  may  be  accomplished  by  having  a  warm  operat- 


POSTOPERATIVE    TREATMENT   IN   OLD   AGE  651 

ing  room,  covering  the  patient  with  previously  warmed  blankets, 
or  surrounding  him  with  hot-water  bags. 

2.  The  preparation  of  the  bed  is  quite  essential.  It  should  be 
prepared  before  the  patient  comes  from  the  operating  room,  i.  e., 
previously  warmed  by  the  use  of  warmed  blankets,  hot-water  bags, 
electric  bakes,  etc. 

3.  When  the  patient  arrives  from  the  operating  room,  he  should 
be  carried  by  at  least  four  people,  and  should  be  gently  placed  in 
bed,  and  snugly  covered.  Hot-water  bags  or  an  electric  bake  may 
be  used  to  maintain  the  desired  warmth  of  the  bed.  It  is  very  es- 
sential that  aged  individuals  receive  all  of  the  heat  possible.  They 
are  in  a  way  analogous  to  an  infant  that  has  to  be  kept  in  an  in- 
cubator.    The  factors  involved  in  the  two  cases  are  quite  similar. 

4.  The  patient's  room  should  be  well  ventilated,  quiet,  and  prop- 
erly heated.  It  is  a  good  idea  to  get  aged  patients  out  into  the 
fresh  air  and  sunshine  as  soon  as  possible ;  and  if  climatic  condi- 
tions are  favorable,  this  point  should  never  be  overlooked. 

5.  The  processes  of  elimination  are  very  frequently  embarrassed 
in  the  aged  by  reason  of  senile  changes  previously  considered. 
Fluids  should  be  forced  unless  some  contraindication  is  present. 
They  may  be  administered  by  rectum,  mouth,  subcutaneously,  or 
into  a  vein.  Patients  should  have  a  daily  bath  and  all  of  the  avenues 
of  excretion  freely  opened. 

6.  Among  all  the  complications  found  in  senility  the  most  feared 
are  perhaps  the  various  forms  of  pneumonia.  For  the  consideration 
of  bronchopneumonia  and  lobar  pneumonia  the  reader  is  referred 
to  any  standard  textbooks  of  medicine.  Ether  pneumonia  and  hy- 
postatic pneumonia  are  the  two  forms  with  which  we  are  directly 
concerned.  The  ether  pneumonia  is  not  so  frequent  in  the  aged  as 
it  was  at  one  time.  It  might  be  disposed  of  by  stating  that  it  is 
always  much  safer  to  give  the  ether  by  the  open  method. 

7.-  Hypostatic  pneumonia  is  primarily  limited  to  aged  individuals 
and  those  who  have  an  enfeebled  cardiovascular  system,  or  to  in- 
dividuals who  lie  in  the  recumbent  position,  or  any  position  at  all 
for  a  long  period  of  time;  the  treatment  is  obvious. 

a.  Patient  must  be  examined  regularly  (always  look  for  physical 
signs  around  the  bases  of  the  lungs). 

b.  Patient  should  be  turned  frequently  and  not  be  allowed  to  oc- 
cupy the  same  position  for  any  great  length  of  time. 

c.  Cardiovascular  and  excretory  systems  should  be  stimulated. 

d.  Free  bleeding  may  be  resorted  to  and  as  much  as  10-20  oz.  of 
blood  may  be  removed.    Some  advocate  aspirating  the  right  auricle, 


652  AFTER-TREATMEXT    OF    SURGICAL    PATIENTS 

but  this  seems  to  be  a   very  heroic   measure   and  should  only  be 
used  as  a  last  resort.3 

Hypostatic  pneumonia  is  always  to  be  feared  in  fracture  cases, 
especially  in  fractures  involving  the  hip  or  spine. 

8.  Bedsores,  or  decubital  ulcers,  are  very  likely  to  occur  in 
bedridden  patients.  The  parts  most  exposed  to  pressure  become  red 
and  congested,  and  finally  ulcerate,  or  gangrene  supervenes.  Bed 
sores  are  not  usually  extensive  or  deep,  but  if  the  patient  is  de- 
bilitated or  paralyzed,  the  process  may  extend  rapidly  and  in- 
volve deeper  structures.  Bed  sores  may  be  so  extensive  as  to  in- 
volve bone,  causing  necrosis  and  caries  (the  so-called  acute  lied 
sore).4  Cases  have  been  known  in  which  the  spinal  canal  was 
opened  up.  and  in  this  way,  death  may  ensue  from  a  meningitis. 
To  prevent  the  occurrence  of  bed  smrs  the  nurse  or  attendant 
should  see  that  the  draw  sheet  and  bed  linen  are  placed  smoothly, 
and  without  creases,  also  that  there  is  no  contamination  by  urine 
or  feces.  "The  skin  of  the  back  should  be  daily  washed  with  some 
nonirritating  soap;  rubbed  with  a  soothing,  strengthening,  and 
hardening  application,  such  as  ;i  mixture  of  brandy  and  white  of 
egg,  then  dusted  over  with  a  powder  consisting  of  equal  parts  of 
zinc  oxide,  starch,  and  boric  acid.  If  the  skin  becomes  red.  it  should 
be  painted  with  a  mixture  of  tincture  of  catechu  and  liquor 
plumbi  subacetatis,  which,  when  dry,  leaves  a  powdery  film  on 
the  surface.  It  must  be  protected  from  pressure  by  a  circular 
water  bag  or  an  air  pillow."1  Paralytic  or  very  debilitated  pa- 
tients should  be  placed  on  an  air  mattress.  When  an  open  sore 
forms,  fomentations  are  required  during  the  more  acute  stages, 
also  irrigations  with  saline  are  very  beneficial;  later  the  open  sore 
may  be  dressed  with  a  boric  acid  ointment;4  occasionally  touching 
up  the  ulcer  with  AgN03  stimulates  granulation,  the  primary  pro- 
cedure, of  course,  being  to  keep  the  open  sores  (dean. 

9.  The  elimination  via  the  gastrointestinal  tract  must  he  assisted 
in  all  cases  of  constipation.  The  condition  or  kind  of  operation 
done,  will,  of  course,  influence  the  administration  of  a  cathartic. 
Ordinarily,  patients  not  having  abdominal  or  rectal  operations 
should  have  a  bowel  movement  al  least  once  a  day.  If  this  is  not 
possible,  any  of  the  following  measures  may  he  resorted  to: 

1.  Saline,  soap  suds,  or  oil  enema t a. 

2.  Castor  oil  or  any  of  the  less  drastic  cathartics. 

3.  In  case  a  fecal  ma^s  becomes  impacted  in  the  lower  sigmoid 
or  rectum,  this  should  be  removed  by  means  of  a  spatula  or  by 
the  fingers. 


POSTOPERATIVE    TREATMENT    IX    OLD    AGE  653 

Constipation  and  gastrointestinal  upsets  are  very  frequent  in  the 
aged,  due  to  the  fact  that  the  musculature  of  the  intestine  becomes 
more  or  less  atonic  and  the  secretions  are  greatly  decreased. 

10.  The  diet  is  one  of  the  most  important  parts  of  the  postopera- 
tive treatment.  As  was  previously  stated,  aged  individuals  are  like 
infants  in  many  respects.5  Their  metabolism  due  to  senile  changes 
is  going  the  wrong  way.  As  was  previously  stated,  the  senile 
changes  of  every  cell  and  gastrointestinal  secretion  have  taken 
place.  So  it  is  evident  that  an  aged  individual  is  not  able  to  me- 
tabolize as  a  younger  person.  It  has  been  estimated  that  an  in- 
dividual at  rest  or  doing  light  work  requires  about  2500  calories. 
This  should  be  composed  of  very  easily  digested  and  tasty  foods. 
Aged  individuals  handle  bland  and  liquid  diets  very  well.  These, 
of  course,  should  be  well  balanced,  they  can  not  take  care  of  the 
heavier  foods.  This  is  partly  due  to  the  fact  that  their  secretory 
functions  are  somewhat  inhibited;  also  their  mastication  is  deficient. 

Senile  individuals  may  be  nourished  frequently  by  the  adminis- 
tration of  eggnogs  and  malted  milk,  which  are  very  nourishing 
and  thankfully  received  by  the  patient.  Here,  again,  the  kind  of 
operation  will  greatly  determine  the  diet,  especially  the  method 
of  administration;  also  if  the  patient  is  a  diabetic  or  a  gouty  in- 
dividual, it  is  the  duty  of  the  dietitian  to  provide  a  diet  which  is 
free  from,  or  very  low  in.  carbohydrates  in .  the  former,  and  a 
very  low  protein,  or  protein-free,  diet  in  the  latter. 

11.  Urinary  retention  is  very  common  in  elderly  individuals. 
This  may  be  due  to  abnormal  conditions  in  the  kidney,  bladder,  cord 
lesion,  prostatic  hypertrophy  or  to  a  urethral  stricture.  As  pre- 
viously stated,  the  sclerotic  kidney  may  be  a  factor  in  diminished 
urinary  output.  The  only  treatment  is  to  force  fluids  and  administer 
diuretics.  The  arterial  condition  is  sometimes  helped  by  giving 
potassium  iodide,  sat.  sol.  gtt.  x  t.i.d.  If  a  calculus  is  the  cause, 
the  only  treatment  outside  of  surgery  is  to  keep  the  patient  free 
of  pain  while  the  stone  is  being  passed.  Patients  very  frequently 
pass  stones  spontaneously,  or  they  may  be  removed  by  mechanical 
means.  Papaverine,  one  of  the  alkaloids  of  opium,  is  supposed  to 
affect  the  musculature  of  the  ureter  in  a  specific  manner,  causing 
a  series  of  relaxations  and  contractions.  This,  however,  is  only 
experimental,  but  may  be  tried.  The  papaverine  should  be  given  in 
%  gr.  doses,  and  not  repeated  oftener  than  every  six  hours. 

The  bladder  may  be  the  etiologic  factor,  the  retention  being 
due  to  an  atonic  musculature  or  to  a  lesion  of  the  central  nervous 
system.     The  senile  bladder  is  very  easily  infected  and  if  one  is 


654  AFTER-TREATMENT    OP    SURGICAL   PATIENTS 

not  strict  in  the  technic  of  catheterization,  a  very  severe  and  per- 
haps fatal  cystitis  may  ensue.  Patients  with  urinary  retention 
should  he  catheterized  regularly.  In  cases  of  prostatic  hypertrophy, 
urethral  spasm  or  stricture,  it  may  lie  very  difficult  to  pass  a  cathe- 
ter. It  is  always  better  to  catheterize  the  patient  according  to  the 
clock  than  to  wait  for  him  to  complain  of  a  full  bladder.  It  is 
also  to  be  borne  in  mind  that  large  catheters  pass  better  than 
smaller  ones.  If  the  retention  is  prolonged  during  the  first  tAVo  to 
three  weeks,  the  patient  should  be  guarded  from  cold  and  exposure. 
Not  infrequently  a  certain  amount  of  fever  is  produced,  which  usu- 
ally passes  off  in  the  course  of  a  few  days,  or  increase,  together 
with  symptoms  of  a  chronic  cystitis  running  on  to  a  fatal  issue  at 
the  end  of  three  to  four  weeks. 

The  only  treatment  of  the  simpler  cases  is  to  keep  the  patient 
warm  in  bed,  to  limit  his  diet,  to  administer  quinine  and  perhaps 
opium  and  to  keep  the  bowels  open.  During  the  continuance  of 
catheter  life,  the  patient  must  be  warned  to  live  very  quietly,  and 
abstain  from  all  excesses,  especially  as  regards  eating  and  drinking; 
strenuous  exercise  must  be  forbidden,  precautions  must  be  taken 
to  insure  protection  from  the  cold  and  dam]).  The  administration 
of  alkalies,  if  the  urine  is  strongly  acid,  so  as  to  diminish  the  irri- 
tability of  the  bladder  is  always  a  good  procedure. 

It  should  always  he  borne  in  mind  that  incontinence  is  never 
present  when  the  bladder  is  empty,  but  is  always  found  when  the 
bladder  is  full.  Incontinence  is  most  frequently  found  in  spinal 
cord  conditions  and  in  prostatic  hypertrophy.  In  this  type  of  pa- 
tient it  is  far  better  that  he  lead  a  catheter  life,  because  if  the 
bladder  is  not  completely  drained,  there  may  result  back  pressure 
phenomena  which  will  lead  to  dilated  ureters  and  hydronephrosis, 
and  ultimately  to  uremia.  It  is  not  an  uncommon  thing  to  see  old 
people  showing  mild  symptoms  of  uremia,  especially  gastrointestinal 
symptoms,  many  of  which  are  due  to  urinary  retention,  and  are  to 
be  relieved  by  proper  catheterization. 

Besides  the  use  of  the  catheter  in  urinary  retention,  hot  stupes 
applied  to  the  suprapubic  region,  hot  rectal  irrigations,  sitz  baths, 
or  perhaps  the  psychologic  effect  of  allowing  the  patient  to  hear 
running  water  will   very  frequently  make  him  void. 

12.  Needless  to  say,  efficient  laboratory  work  consisting  of  com- 
plete urine  and  blood  examinations  should  he  routinely  done. 
Urinary  findings  have  a  special  meaning  clinically  in  an  aged  in- 
dividual, for  as  previously  stated,  we  always  expect  to  find  a  few- 
hyaline  casts  or  perhaps  a  trace  of  albumin. 


POSTOPERATIVE  TREATMENT  IN  OLD  AGE  655 

In  the  previously  mentioned  points  we  have  summed  up  the  more 
important  things  to  be  thought  of  in  the  postoperative  treatment 
in  the  aged.  Be  it  always  borne  in  mind  that  the  aged  individual 
is  on  the  downward  trend  and  does  not  respond  to  treatment  like 
a  younger  adult. 

Full  credit  is  due  C.  R.  Fancher  for  having  abstracted  all  the  lit- 
erature to  which  reference  is  made  in  this  chapter. 

Bibliography 

iMacCallum,  J.  M. :     Pathology,  Philadelphia,  1917,  W.  B.  Saunders  Co. 

2Von  Miihlmann:     Das  Altern  und  der  physiologische  Forderungen  zur  physiolo- 

gisehen  Wachsturnslehre,  1910. 
sOsler:     Medicine,  1918. 

4Rose  and  Carless:     Manual  of  Surgery,  New  York,  1917,  Wm.  Wood  &  Co. 
sLusk:      Science  of  Nutrition,  Philadelphia,  1917,  W.  B.  Saunders  Co.,  ed.  3. 

The  following  references  were  also  consulted : 
Charcot,  J.  M. :     Diseases  of  Old  Age,  1881.    " 
Manning,  Chas. :     Child,  Senescence,  and  Rejuvenescence,  1915. 
Meyer,  A.  W. :     Lectures  on  Osteology,  1916,  Stanford  University. 
Minot:     Age,  Growth,  and  Death,  1912. 

Rubner:  von  Leyden's  Handbuch  der  Ernahrungstherapie,  1903,  i,  153. 
Stimson:   Textbook  of  Fractures  and  Dislocations,  Philadelphia,  Lea  and  Febiger. 


CHAPTER  LXI 

SYMPTOMS  AND  SIGNS  OF  IMPENDING  DEATH" 
By  0.  F.  McKittrick,  St.  Louis,  Mo. 

At  the  door  of  each  and  every  life  the  grim  reaper  deatli  will 
knock.  Just  when  and  how  it  will  come  no  one  can  tell,  and  yet 
in  spite  of  the  millions  of  observations  upon  this,  the  most  tragic 
phenomenon  of  life,  practically  nothing'  has  been  written.  Neither 
have  very  great  efforts  been  made  to  critically  study  this  phase 
of  disease,  and  we  of  the  twentieth  century  must  suffer  the  con- 
secpiences  of  our  negligent  medical  forefathers.  It  is  a  matter  of 
common  observation  that  the  relatives,  particularly  the  women  who 
nurse  the  sick  one,  feel  the  presence  of  this  weird  specter  much 
more  quickly  ami  keenly  than  does  the  physician  himself.  Possi- 
bly if  he  could  have  seen  so  far  as  they,  a  different  and  more  effi- 
cient treatment  might  have  been  given  with  years  of  useful  life 
added  to  the  patient's  career.  At  any  rate,  if  the  possibility  of 
death  could  be  foretold,  the  prognosis  would  be  less  often  faulty. 

The  signs  of  impending  death  were  first  commented  on  by  Hip- 
pocrates 2500  years  ago.  Nothing  of  material  importance  has  been 
added  since  his  time  except  a  few  facial  sinus  noted  by  the  late 
Austin  Flint.  Others  have,  no  doubt,  attempted  work  along  this 
line  only  to  have  their  efforts  discouraged  by  the  tradition  that 
patients  often  get  well  despite  the  sentence  of  death  pronounced  by 
the  medical  judge. 

The  medical  profession  is  not  only  called  upon  to  answer  this 
question  thousands  of  times  daily.  bu1  a  correct  solution  of  the 
problem  is  now  required  also  by  certain  municipalities.  Failure  to 
realize  that  death  is  certain  within  forty-eight  hours  of  the  time 
a  patient  is  moved  from  one  institution  to  another  is  punishable  by 
a  fine.  However,  no  one  can  say  in  the  light  of  our  present  day 
knowledge  of  medicine  jusl  when  fatal  outcome  might  develop  in 
the  course  of  such  complications  as  angina  pectoris,  myocarditis. 
cerebral  hemorrhage,  postoperative  thrombosis  or  nephritis. 
Neither  can  the  sudden  unaccountable  deaths,  which  occur  daily 
in  hospitals,  be   foretold.     Such  instances  are  rather  an   exception. 


'Much   of   the   matter   in   this   chapter   is   taken    from    Reilly's   article:    Signs   ami    Symptoms 
of  Impending  Death,  Jour.   Am.   Med.   Assn  .    1916,  lxvi,   160. 


SYMPTOMS   AND    SIGNS    OF   IMPENDING   DEATH  657 

and  are  not  included  in  the  class  of  cases  which  is  discussed  in  the 
following. 

According  to  Reilly1  "death  usually  occurs  as  a  result  of  heart 
failure,  respiratory  failure,  asthenia,  vagus  failure,  or  shock."  When 
this  last  occurs,  however,  the  centers  in  the  medulla  are  the  con- 
trolling factors  rather  than  any  one  organ. 

There  are  few  single  symptoms  pathognomonic  of  death,  but  when 
two  or  more  are  considered,  a  positive  statement  regarding  its  ap- 
proach often  can  be  made.  In  the  following  sentences  Reilly  men- 
tions, in  the  order  of  their  importance,  some  of  the  more  common 
danger  signals  which  warn  us  of  the  oncoming  scythe-bearer.  When 
one  of  them  is  present  others  are  also  very  apt  to  assert  themselves. 

An  irregular  pulse  for  the  first  time  in  the  disease  or  its  dis- 
appearance from  the  wrist  with  the  patient  recumbent  is  alarming, 
except  in  cardiac  disease  or  in  sudden  severe  hemorrhage.  In  the 
latter  if  there  is  much  factitious  behavior,  death  invariably  occurs. 

Pulsus  alternans,  appreciated  by  the  finger,  means  death  within 
a  short  time.     This  is  most  common  in  fractures  of  the  skull. 

In  adults,  except  in  heart  block,  a  pulse  under  80  means  that 
death  is  at  least  twelve  hours  away.  In  the  aged,  however,  the 
pulse  is  often  slow  until  death.  In  these  old  people  a  pulse 
of  140  means  death  within  a  few  hours.  In  children  with  a  pulse 
under  120,  death  is  rare  within  six  hours.  A  pulse  of  100  in 
coma  usually  means  that  death  is  eight  hours  off  at  the  most. 
Such  statements  are  taken  to  mean,  of  course,  that  the  pa- 
tient is  safe  for  this  length  of  time.  A  pulse  mounting  gradually 
to  160  presages  death,  except  in  pericarditis ;  and  generally  speak- 
ing, a  pulse  which  increases  in  rapidity  hour  by  hour  is  adequate 
warning  of  approaching  death  provided  other  signs  of  very  serious 
illness  are  present;  but  the  approach  can  not  be  foretold  by  the 
pulse  as  reliably  in  children  and  the  aged  as  in  adults. 

Cases  of  auricular  flutter  are  very  deceptive,  the  pulse  may  be 
150  or  more  with  extreme  prostration,  and  still  recovery  often 
occurs. 

Gallop  rhythm,  not  associated  with  rheumatic  endocarditis,  is 
always  fatal.  Of  like  import,  is  a  persistent,  firm  pulse  in  coma 
accompanied  by  hemiplegia.  In  all  infectious  diseases  a  strong  pul- 
monary valve  sound  indicates  that  immediate  fatal  termination  is 
improbable. 

In  very  sick  patients  who  are  free  from  cardiac  disease,  a  dis- 
appearance  of  the   pulse   at   the   wrist   when   the   hand   is   raised 


658  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

vertically  above  the  head,  indicates  that  the  end  may  be  expected 
within  twenty-four  hours. 

Blood  pressure  change  is  not  as  good  an  indication  of  impending 
death  as  one  would  suppose,  probably  because  of  the  fact  that  it 
is  not  practical  to  have  observations  made  often  enough.  We  know, 
however,  that  the  blood  pressure  steadily  drops  as  the  end  ap- 
proaches. 

A  blood  pressure  of  230  falling  suddenly  below  100  without  hemor- 
rhage, means  a  fatal  issue;  likewise  when  it  steadily  falls  in  any 
adult  to  40. 

Cheyne-Stokes'  respiration  in  the  sick  practically  always  heralds 
death  except  in  uremia  or  cardiorenal  disease.  Rapid  breathing 
following  this  phenomenon  indicates  that  it  is  at  hand. 

A  marked  disproportion  between  inspiration  and  expiration,  espe- 
cially if  accompanied  by  rapid  pulse,  except  in  shock  or  hemor- 
rhage, is  a  terminal  sign.  Continued  sighing  under  these  same  con- 
ditions of  sternomastoid  breathing  in  a  patient  free  from  asthma 
or  obstruction  to  the  larynx,  heralds  death. 

According  to  Shrady,  a  persistent  up  and  down  motion  of  the 
Adam's  apple  foreshadows  a  rapidly  fatal  outcome.  "White  frothy 
mucus  from  the  nostrils  announces  the  end. 

Absence  of  pupillary  reaction  to  light  except  in  syphilis,  brain 
diseases,  optic  atrophy,  fainting  or  hemorrhage  immediately  pre- 
cedes death ;  a  sluggish  reaction  is  serious.  In  most  cases  the  pupil 
dilates  widely  just  before  the  end. 

A  film  over  the  eyes  or  tight  closing  of  the  eyelids,  with  a  firm, 
rapid  pulse,  is  a  sign  of  impending  fatality,  as  is  a  turning  of  the 
eyes  outward. 

In  children  a  passive  congestion  of  the  conjunctival  vessels  means 
approaching  death. 

Other  signs  which  no  doubt  are  noticed  even  before  those  men- 
tioned above,  but  which  are  of  secondary  prognostic  value,  are 
stated  below. 

The  facies  show  markedly  the  hand  of  death ;  there  is  noted  a 
pallor,  the  eyes  are  sunken  and  hollow,  the  temples  are  collapsed, 
the  nostrils  are  pinched,  and  the  ears  which  are  cold  and  trans- 
parent have  the  lobes  turned  outward.  Finally  the  lower  jaw 
drops,  the  eyes  become  fixed  and  a  haziness  comes  over  the  cornea. 
Aside  from  any  intrinsic  pain  there  appears  a  look  of  great  mental 
distress,  though  the  patient  is  unmindful  of  the  fact.  It  seems  as 
though  the  body  is  conscious  of  the  impending  danger,  while  the 
mind  is  oblivious  to  it.     In  such  a  facies  every  one  recognizes  the 


SYMPTOMS   AND   SIGNS    OF   IMPENDING   DEATH  659 

fact  that  death  has  already  opened  the  door  for  the  final  departure. 

A  temperature  of  108°  F.,  except  in  heatstroke,  is  fatal;  likewise 
a  rising  temperature  on  the  second  day  after  the  onset  of  hemi- 
plegia. 

Loss  of  sphincter  control  is  always  a  grave  sign,  especially  when 
coma  is  present. 

In  peritonitis  a  fatal  indication  is  a  bright  yellow  discoloration 
of  the  tongue ;  likewise,  black  vomit  coming  on  forty-eight  hours 
after  operation. 

Persistent  and  uncontrollable  hiccough  appearing  in  a  serious 
complication  is  usually  the  forerunner  of  death. 

The  appearance  of  large  amounts  of  indican  in  the  urine  or 
transudates  is  a  fatal  indication.  Subsultus  tendinum  and  car- 
phologia,  except  in  typhoid,  are  of  grave  import. 

Fibrillary  heart-tremor  in  electric  shock  is  always  fatal. 

Except  in  diseases  of  the  central  nervous  system,  the  disappear- 
ance of  the  peripheral  reflexes  is  usually  a  fatal  sign. 

Edema  of  the  glottis  in  patients  over  45  years  of  age  is  followed 
by  death  in  a  few  hours. 

It  has  been  said  that  there  is  a  peculiar  odor  to  the  breath  in 
many  dying  patients.  In  rooms  which  have  not  had  the  best  of 
ventilation,  this  is  especially  noticed.  It  is  likened  unto  decayed 
apple  blossoms  or  acetone.  Some  think  it  resembles  horse-radish 
very  closely.    When  once  noticed  it  is  not  soon  forgotten. 

Fortunately  few  patients  realize  that  death  is  at  hand.  The 
most  prominent  passion  during  life  will  very  likely  present  itself 
during  the  last  hours.  The  loss  of  interest  at  this  time  in  things 
which  formerly  interested  the  patient,  is  a  bad  sign. 

The  presentiment  of  a  fatal  issue  by  the  patient  in  cases  where 
the  condition  is  not  particularly  alarming,  and  when  he  shows  very 
little  or  no  interest  in  the  consultation  over  his  bedside,  is  not  en- 
couraging. Likewise  when  a  uremic  patient  becomes  jolly  and 
joyous,  the  end  is  often  very  near  at  hand. 

More  than  half  of  our  patients  die  in  coma.  The  blood  pressure 
falls,  the  pulse  becomes  fast  and  ultimately  irregular,  the  skin  be- 
comes cold  and  clammy,  finally  the  well-known  death  rattle  appears 
in  the  throat  and  the  end  has  come. 

Sudden  Death. — Sudden  death  is  not  uncommon  among  individ- 
uals who  were  previously  known  to  be  the  victims  of  no  disease. 
Should  it  then  be  a  matter  of  surprise  that  this  distressing  accident 
occasionally  happens  among  those  who  have  recently  been  sub- 
jected to  the  stress  and  strain  of  a  major  surgical  procedure? 


660  AFTER-TREATMENT    OF    SURGICAL    PATIENTS 

Few  operators  indeed  escape  the  occurrence,  at  some  time  or 
other  during  their  experience,  of  sudden  unexpected  and  unex- 
plained deaths  among  their  patients.  Many  eases  are  reported  in 
the  literature,  but  many  more  have  passed  unnoticed,  not  gaining 
the  attention  of  the  medical  profession  at  all.  During  recent  years, 
however,  more  light  has  been  shed  on  this  subject  with  the  result 
that  through  the  efforts  of  Draper.2  1850  cases  have  been  collected. 
Ferrario  and  Sermoine  of  Milan  studied  1043  cases,  Wescott,  coroner 
for  Middlesex  district,  London,  reported  303  instances,  and  Bro- 
nardel  of  France  called  attention  to  1000  cases  more.  Later  on 
Blake  in  this  country  collected  225  eases.  These  figures  are  suffi- 
cienl  to  show  that  a  factor  uncontrolled  by  any  means  on  the  part 
of  the  surgeon  must  be  reckoned  with  in  surgery,  and  that  this 
factor  is  not  of  little  importance. 

The  p<  riod  of  life  during  which  sudden  death  is  most  apt  to  oc- 
cur, according  to  the  various  mortuary  records,  seems  to  be  after 
the  age  of  55.  Nex1  in  frequency  comes  the  span  between  40  and 
55,  while  about  one-fourth  of  all  sudden  deaths  occur  before  40. 
It  must  therefore  be  apparent  that  youth  and  even  childhood  are 
not  entirely  free  from  this  occurrence. 

The  causes  which  are  usually  given  in  death  certificates  for  these 
unexpected  deaths,  are  status  lymphaticus,  myocarditis,  ar- 
teriosclerosis (particularly  of  the  coronary  arteries),  thrombosis 
and  embolism,  of  which  the  pulmonary  variety  forms  80  per  cent, 
hemorrhage  from  the  pancreas,  acute  dilatation  of  the  heart,  rup- 
ture of  the  heart,  and  valvular  lesions  of  the  heart.  Recently 
the  thymus  gland  in  children  and  young  adults  has  been  noted  as  a 
causative  factor  as  reported  by  Rehn,3  Colin.'  Lange,5  Zander  and 
Keyhl,6  Caille,7  Falls/  Hart.'1  Mettenheimer,10   Forret11  and  others. 

The  conditions  under  which  these  deaths  occurred,  according  to 
Blake12  who  particularly  studied  this  phase  in  his  own  collection 
of  cases,  were  the  following:  (a)  unusual  exertion,  one-fifth;  (b) 
moderate  exertion,  one-fourth;  (c)  deep  emotion  or  psychic  shock 
less  than  one-fifth;  (d)  the  remaining  cases  occurred  during  rest 
or  sleep. 

Blake  therefore  concludes  that  emotion,  exercise,  and  exertion 
are  frequently  the  exciting  cause  of  sudden  death.  These  same 
factors  are  attendant  upon  a  surgical  operation.  Be  further  states 
that  the  effects  of  apprehension  and  fright  are  very  obvious,  while 
the  effect  of  the  anesthetic  upon  the  pulse,  respiration,  skin,  and 
kidneys  is  precisely  thai  of  moderate  exercise;  furthermore,  the  ef- 
fects of  long-continued  and  very  serious  surgical   interference  are 


SYMPTOMS   AND   SIGNS    OF    IMPENDING   DEATH  661 

again  precisely  analogous  to  very  severe  exertion.  We  have,  there- 
fore, in  the  routine  of  modern  surgery,  reproduced  with  considerable 
accuracy  the  precise  conditions  under  which  a  majority  of  sudden 
deaths  occur.  The  deaths  which  have  been  attributed  to  the  anes- 
thetic are  more  than  likely  coincidental  and  would  have  occurred 
with  equal  certainty  under  any  other  procedure  which  produced 
these  conditions. 

Considerable  work  has  been  done  in  attempting  to  determine 
the  cause  of  sudden  deaths  under  anesthetics.  Henderson13  states 
that  most  of  the  deaths  belong  in  one  or  the  other  of  two  general 
classes:  those  the  result  of  primary  respiratory  failure,  and 
caused  by  a  cessation  of  the  heart  beat.  It  is  well-known  that 
carbon  dioxide  in  the  blood  is  the  normal  stimulant  to  the  re- 
spiratory center.  This  is  maintained  at  a  constant  level  Jby  the 
normal  breathing.  During  anesthesias,  however,  the  sensitiveness 
of  the  respiratory  center  is  very  much  altered.  Too  light,  and 
especially  an  intermittent,  administration  of  the  anesthetic,  ether 
excitement,  fear,  pain,  and  intense  emotion,  which  may  accompany 
the  anesthesia  at  times,  increase  this  sensitiveness  greatly,  produc- 
ing at  once  ver}^  rapid  respiration,  which  in  turn  overventilates  the 
lungs.  This  causes  a  decrease  of  the  carbon  dioxide  of  the  blood, 
and  a  condition  known  as  acapnia.  The  respiration,  receiving  no 
further  stimulation  from  the  inadequate  amount  of  carbon  dioxide, 
soon  ceases.  Unless  artificial  respiration  is  at  once  instituted,  the 
patient  dies. 

The  acapnia  not  only  causes  an  increased  sensitiveness  of  the  re- 
spiratory center,  but  this  condition  produces  deleterious  effects  upon 
the  heart.  This  organ  becomes  under  those  new  conditions  hyper- 
susceptible  to  the  anesthetic,  so  that  the  amount  which  under  normal 
conditions  would  not  be  harmful,  is  now  sufficient  to  cause  it  to  even 
cease  its  contractions.  When  this  occurs  before  the  respiration 
ceases,  the  case  is  considered  as  belonging  to  the  cardiac  class. 

Woolsey,14  while  not  decrying  the  acapnia  theory  of  Henderson, 
states  that  "any  agent  capable  of  so  changing  the  molecular  state 
of  nerve  matter  as  to  arrest  its  function  if  carried  into  the  blood, 
first  acts  upon  the  nerve  cells.  Each  change  produced  in  one  of 
these,  be  it  the  decomposition  of  a  molecule  or,  as  is  more  probable, 
the  isomeric  transformation  of  a  molecule,  implies  a  disengagement 
of  molecular  motion  or  nerve  force,  that  is  immediately  communi- 
cated to  neighboring  molecule,  each  molecule  being  a  center  of  dis- 
charged nerve  force,  and  in  the  act  of  being  incapacitated  for 
further  transmittal  of  motion."     He  further  informs  us  that  the 


C62  AFTER-TREATMENT   OF   SURGICAL   PATIENTS 

nerve  cell  then  being  quickly  acted  upon  and  discharging  as  quickly 
as  the  successive  molecular  transformations  are  wrough  in  it,  there 
results  a  general  nervous  chaos,  a  tempest  of  incoordinate  nerve 
force  discharge,  and  as  can  be  easily  seen  a  corresponding  disor- 
ganization of  the  action  of  vital  organs  which  depend  upon  fine 
nervous  coordination  for  their  control. 

The  surgical  procedure  with  its  attending  trauma  has  as  primary 
causative  factors,  first,  the  afferent  nerve  assault  of  fear  and  ap- 
prehension of  the  operation ;  second,  the  afferent  nerve  assault  of 
the  anesthetic,  especially  if  it  is  imperfectly  maintained  throughout 
the  operation;  third,  the  afferent  nerve  assault  of  the  operative  per- 
formance and  the  condition  for  which  it  was  performed. 

All  these  elements,  in  greater  or  lesser  degree,  combine  toward 
the  end  of  determining  the  degree  of  central  nerve  disorganization 
which  Woolsey  believes  is  the  cause  of  fatal  terminations  of  other- 
wise good  operative  risks. 

The  more  we  know  of  the  real  nature  of  these  sudden  deaths,  the 
better  we  shall  be  able  to  avoid  them.  As  has  been  said  before, 
no  one  can  designate  with  certainty  the  individual  who  is  doomed 
to  suddenly  die,  or  the  time  or  manner  of  its  occurrence,  but  Ave 
do  know  many  of  the  pathologic  conditions  which  predispose  to  it 
and  the  circumstances  under  which  it  is  most  apt  to  occur. 

While  attention  has  already  been  called  to  the  complications 
which  most  frequently  cause  death,  special  notice  must  be  taken 
of  status  lymphaticiis  which  is  comparatively  frequent;  and  there 
is  another  condition  known  as  status  thymicolymphaticus  in  which 
an  enlarged  thymus  gland  is  found  in  association  with  the  general 
enlargement  of  the  lymphatic  tissue.  Not  alone  does  this  condition 
materially  complicate  operations  upon  children,  but  it  has  caused 
sudden  death  in  adults,  particularly  in  goiter  operations,  as  re- 
ported by  Rehn,  Gluck,  and  Dwornitschenko. 

In  order  to  diminish  the  instance  of  such  calamities  it  is  ab- 
solutely necessary  for  more  thorough  histories  to  be  taken  and 
complete  examinations  of  patients  to  be  made  before  operations, 
even  of  a  minor  character,  are  attempted. 

It  is  also  important  to  try  as  far  as  possible  to  diminish  preanes- 
thetic fright,  apprehension  and  intense  emotion. 

Every  case  which  unfortunately  terminates  in  this  way  should 
have  an  autopsy.  By  Ihis  means  additional  causes  may  be  found 
and  more  information  be  obtained  to  stimulate  careful  scrutiny  of  a 
subject,  which  has  so  often  been  a  matter  of  great  humiliation  and 
sorrow. 


SYMPTOMS   AND   SIGNS    OF   IMPENDING   DEATH  663 


Bibliography 

lEeilly:     Jour.  Am.  Med.  Assn.,  1916,  lxvi,  160. 

sDraper:     A  Text  Book  of  Legal  Medicine,  1907. 

sRehn:     Arch.  f.  klin.  Med.,  1906,  lxxx,  468. 

^Colm:     Deutseh.  med.  Wchnsehr.,   1901. 

sLange:     Verhandl.  d.   Gesellsch.  if.  Kinderb.,  Karlsbad,  December,   1902. 

sZander  and  Keyhl:     Ibid. 

^Caille:     Arch.  Pediat.,  N.  Y.,  1903,  xx,  180. 

sFalls:     Surg.,  Gynec.  and  Obst.,  1916,  xxii,  713. 

9Hart:     Mitt.  a.  d.  Grenzgeb.  d.  Med.  u.  Chir.,  1909,  xii,  321. 
loMettenlieimer :     Jahrb.  f.  Kinderh.,  1897,  p.  655. 
nForret:     Theses  de  doct.,  Paris,  1896. 
"Blake:     Ann.  Surg.,  1909,  1,  43. 

isHenderson :     Surg.,  Gynec.  and  Obst.,  1911,  xiii,  161. 
lAVoolsey:     Surg.,  Gynec,  and  Obst.,  1912,  xiv,  350. 


CHAPTEE  LXII 

POSTOPERATIVE  MO-RTALITY 
By  Willard  Bartlett.  and  B.  L.  Adelsberger,  St.  Louis.  Mo. 

Postoperative  mortality,  as  it  will  be  discussed  iu  this  chapter, 
will  be  subdivided  into  two  groups;  surgical  mortality,  and  opera- 
tive mortality.  By  surgical  mortality  we  mean  the  death  of  the  pa- 
tient  from  any  cause  if  that  patient  has  been  operated  upon.  By 
operative  mortality  we  mean  the  death  which  is,  directly  or  in- 
directly, the  result  of  the  operation;  the  disease  for  which  the  op- 
eration was  performed  not  necessarily  being  fatal.1  These  mortality 
figures,  however,  are  largely  influenced  by  the  type  of  cases  re- 
ported. Under  the  list  of  surgical  mortalities  we  shall  attempt  to 
give  the  mortality  rate  from  anesthetics,  and  under  operative  mor- 
talities, the  mortality  rate  from  the  various  operations  themselves. 
In  connection  with  this  it  will  be  also  necessary  to  discuss,  briefly, 
the  relationship  of  anesthetic  mortality  and  postoperative  complica- 
tions. 

As  a  matter  of  historical  interest  it  might  be  permissible  to  men- 
tion a  few  facts  regarding  the  introduction  of  ether  anesthesia,  its 
mortality  then  and  follow  it  roughly  up  to  the  present  time. 

The  Medical  GazetU  on  March  5,  1847.  reported  28  operative  cases 
in  which  ether  had  been  used  as  an  anesthetic — 2  of  these  cases 
were  fatal.  In  the  same  year  the  London  Chemist  for  April  re- 
ported another  death  from  ether  anesthesia  in  which  the  patient 
failed  to  recover  from  the  effects  of  the  ether.  This  fact,  failure 
to  recover  from  the  effects  of  ether  or  death  before  the  anesthesia 
was  complete  caused  physicians  to  fear  the  use  of  ether,  and  led 
Sir  James  Y.  Simpson  to  investigate  the  anesthetic  value  of  chlo- 
roform. However,  the  dangers  of  chloroform  were  immediately  seen 
by  an  initial  fatality  on  Jan.  28,  1848,  and  then  both  ether  and  chlo- 
roform were  regarded  as  being  unsafe.  In  1^>4  The  Royal  Medical 
and  Chirurgical  Society  reported  100  deaths  from  chloroform,  cov- 
ering a  period  of  years  from  1848  to  1865.  From  1865  to  1876,  101 
more  deaths  from  chloroform  were  reported  and  of  these  210  deaths, 
90  per  cent  occurred  before  the  anesthesia  was  complete.  From  ISSli 
to  1889,  130  chloroform  deaths  were  reported.  54  per  cent  of  which 
occurred  either  before  or  during  the  operation.-'  The  mortality  rate 
is  thus  shown  to  be  very  high  and  the  true  cause  of  death  was  not 


POSTOPERATIVE    MORTALITY  665 

fully  appreciated  until  the  relationship  between  cardiac  fibrillation 
and  chloroform  syncope  was  realized.  Levy3  in  analyzing  the  cases 
reported  by  the  Royal  Medical  and  Chirurgical  Society  in  1864,  states 
that  in  62  per  cent  of  the  cases  it  was  shown  that  the  patients  died 
under  light  anesthesia  and  that  87  per  cent  of  the  deaths  were  not 
due  to  an  overdose;  also,  that  out  of  the  whole  series  of  98  cases 
there  is  no  evidence  that  any  patient  died  of  overdosage.  From 
this,  he  concludes  that  these  deaths  are  due  only  to  cardiac  fibril- 
lation and  chloroform  syncope. 

In  1912,  71,052  cases  of  anesthesia  administration  with  24  deaths 
were  reported.4  Of  these,  20,613  were  chloroform  administrations, 
death  occurring  1  in  every  2,060  cases;  11,859  were  ether  cases  with 
a  fatality  of  1  in  5,930.  This  series  also  includes  10,230  cases  in 
which  chloroform  was  the  primary  anesthetic  followed  by  ether. 
The  mortality  here  was  1  in  3,410  cases.  In  the  same  year  Bevan 
at  the  American  Medical  Association  meeting  reported  the  following 
deductions : 

1.  That  the  use  of  chloroform  as  an  anesthetic  for  major  opera- 
tions is  no  longer  justifiable. 

2.  That  for  minor  operations  the  use  of  chloroform  should  cease. 

3.  That  chloroform  is  sometimes  found  convenient  in  initiating 
anesthesia  in  alcoholics  or  difficult  subjects. 

The  first  two  points  have  been  accepted  without  hesitation,  but 
in  regard  to  No.  3  recent  investigations  show  that  chloroform  should 
never  be  used  as  a  preliminary  drug. 

In  obtaining  figures  for  anesthetic  mortalities  at  the  present  time 
one  meets  with  many  difficulties.  To  determine  the  total  number 
of  administrations  would  be  impossible ;  also,  we  can  not  find  any 
standard  by  which  we  can  determine  what  constitutes  an  anes- 
thetic death.  Various  opinions  have  been  given  and  a  few  are 
mentioned.  Roberts5  concludes  that  death  in  general  anesthesia  in 
the  majority  of  cases  is  due  to  improper  administration  of  the  drug 
with  subsequent  poisoning.  Williams6  believes  that  anesthetic 
deaths  reported  as  such  are  not  always  the  result  of  the  anesthetic. 
Other  men  attribute  status  lymphaticus  as  a  cause.  Henderson7 
says  that  "in  a  large  majority  of  deaths  of  cardiac  type,  the  ex- 
pressions hypersensibility  to  anesthesia,  heart  disease,  or  status 
lymphaticus  are  mere  excuses,  and  that  the  patient  is  killed  by 
the  method  of  administration  of  the  drug."  He  further  says  that 
it  is  not  the  anesthetic  agent  at  the  time  which  kills  the  patient,  but 
instead,  the  treatment,  which  the  patient  receives  half  an  hour  or 
so  earlier  is  really  the  cause  of  death. 


666 


AFTER-TREATMENT    OF    SURGICAL    PATIENTS 


Many  deaths  which  occur  during  or  following  an  operation  can 
not  be  said  definitely  to  be  caused  by  the  anesthetic,  neither  can 
we  definitely  estimate  the  influence  the  anesthesia  had  in  produc- 
ing these  deaths.  In  such  cases  of  postoperative  deaths  the  result 
of  septicemia,  peritonitis,  hemorrhage  and  emboli  of  the  lungs, 
heart,  or  brain,  Ave  can  not  consider  the  anesthetic  as  a  cause  of 
death.  In  cases  of  death  the  result  of  aspiration  pneumonia,  suffo- 
cation from  pressure  on  the  larynx  during  operation,  we  again 
can  not  lay  the  cause  of  death  to  the  anesthetic,  although  death 
might  not  have  occurred  had  no  anesthesia  been  given.  So  in  giv- 
ing the  figures  on  anesthetic  deaths,  Ave  hope  to  adhere  as  closely  as 
possible  to  those  occurring  from  overdosage  or  improper  adminis- 
tration, bearing  in  mind  that  with  improper  administration  such 
complications  as  cardiac  and  respiratory  failure  may  result.  We 
must  also  consider  those  deaths  due  to  delayed  chloroform  poisoning, 
of  which  82  are  reported  in  the  literature.8  Braun  states  that  late 
chloroform  poisoning  presents  the  picture  of  acute  yellow  atrophy 
of  the  liver.  Graham0  attributes  it  to  the  HO  set  free  in  the  tis- 
sues when  the  chloroform  is  oxidized. 

The  mortality  rates  from  various  anesthesias  Avill  be  considered  as 
follows:    Deaths  under: 

I.  Ether. 
II.  Chloroform. 
III.  Ethyl  Chloride. 
IV.  Nitrous  Oxide-oxygen. 

V.  Spinal  Anesthesia. 
VI.  Scopolamine. 
VII.  Local  Anesthesia. 
VIII.  Other  methods. 


I  and  II.     Under  Ether  and  Chloroform 


UNDER    ETHER 

UNDER   CHLOROFORM 

REPORTER 

CASES 

DEATHS 

MORTALITY 

RATE 

C  k.SES 

DEATHS 

RATE 

Eiehardsonio 

Julliardii 
Ormsbee12 
St.  Barth. 
Hospital13 

German  Sur. 

Society  I* 
Neuberis 
GwathmeyiG 
McGrath" 

8,431 

314,738 

92,815 

37,277 

56,333 

1  L,859 

294,653 

49,057 

1 

21 

4 

4 

11 

2 

65 
0 

1 

1 

1 

1 
1 
1 

in 

in 

in 

in 
in 

in 

1  t,987 
23,204 

8,318 

5,121 
5,930 

4  ^33 

35,162 
524,507 

152,260 

I2.9S7 

240,806 
20,613 
L6,390 

1,300 

11 

161 
53 

33 

116 

10 
8 
0 

1 
1 
1 

1 

1 
1 
1 

in   3,196 
in  3,258 
in   2,837 

in   1,300 

in  2.075 
in    2,061 

in  2,04S 

Average  mo 

rtality  rat 

c 

1 

in 

8,010 

1 

in  2,665 

POSTOPERATIVE    MORTALITY 


667 


The  average  mortality  under  ether  was  0.012  per  cent  while  that 
under  chloroform  was  0.038  per  cent  or  three  times  that  under  ether. 
W.  H.  Keen  has  collected  262,002  cases  of  ether  administration 
from  various  sources,  with  34  fatalities;  the  mortality  being:  1  in 

7,705.1S 

III.     Under  Ethyl  Chloride 


REPORTER 

CASES 

DEATHS 

REFERENCE 

Soullier 

8,417 

0 

Bull.  Med.  Paris,  1895. 

Lotheissen 

2,550 

1 

Ware:     Med.  Rec,  April,  1901. 

Newman 

1,867 

1 

Cumston:  Boston  Med.  and  Surg.  Jour., 
January,  1905. 

MeCardie 

12,000 

4 

British  Med.  Jour.,  March,  1906. 

Luke 

2,000 

0 

Lancet,  London,  May,  1906. 

Lee 

5,575 

1 

Internal  Clinics,  iv,  19th  Series. 

Herrenknecht 

3,000 

■1  i '  8 

0 

Munchen.  med.  Wchnschr.,  December, 
1907. 

Webster 

1,880 

0 

Surg.,   Gynec.   and   Obst.,  April,   1909. 

Steida 

1,000 

0 

Med.  Klin.,   March,  1912. 

Zanda 

Miller 

6.648 

1 

Jour.  Am.  Med.  Assn.,  November,  1912. 

Hornabrook 

18,813 

0 

Austin  Med.  Gaz.,  April,  1914. 

Greene 

5,000 

0 

Am.   Jour.   Surg.,   July,   1915. 

Ware 

15,000 

0 

Am.  Jour.  Surg.,  July,  1915. 

In  addition  Peterka19  reports  9  deaths  out  of  100,971  cases  of 
ethyl  chloride  anesthesia,  or  a  mortality  rate  of  1  in  11,219.  Out 
of  53,403'  cases  collected  by  Miller20  he  reports  4  deaths  or  a  mor- 
tality of  1  in  13,365. 

IV.     Under  Nitrous  Oxide-Oxygen 


REPORTER 


CASES 


DEATHS 


REFERENCE 


Gwathmey 

Jones 

Lower  and  Crile 

Teter 


8,585 
13,000 
34,946 
23,952 


Jour.  Am.  Med.  Assn.,  Nov.,  1912. 
Ohio  State  Med.  Jour.,  Aug.,  1915. 
Anoci-Association,  1915. 
Jour.  Am.  Med.  Assn.,  November,  1912. 


Of  1,500,000  cases  collected  and  reported  in  the  Birmingham 
Medical  News  for  April,  1893,  2  deaths  were  recorded.  Buxton  in 
190021  reports  1,001,000  cases  with  one  death.  The  mortality  rate 
by  others,  Gwathmey22  has  been  placed  as  1  in  20,000  which  might 
be  considered  high  as  compared  with  others. 

V.    Under  Spinal  Anesthesia 


REPORTER 

CASES 

DEATHS 

REFERENCE 

Risch 

Chaput 

Kronig  and   Gauss 

Colombani 

Gray 

Hohmeier 

315 

7,000 
1,000 
1,100 
300 
2,400 

2 
0 
3 
0 
1 
12 

Zeit.  f.  Gyn.,  July,  1907. 
Anesthesia;   Gwathmey,  1914. 
Munchen.  med.  Wchnschr.,  Oct.,  1907. 
Wien.  klin.  Wchnschr.,  Sept.,  1909. 
Anesthesia,  Gwathmey,  1914. 
Arch.  f.  klin.  Chir.,  xciii,  No.  1. 

Jonnoesco 

2,963 

2 

Bull,  de  L'Acad.   de  Med.,  1910. 

668 


AFTER-TREATMENT   OF    SURGICAL   PATIENTS 


V.     Under    Spinal   Anesthesia — Continued. 


REPORTER 

CASES 

DEAT 1 1  S 

REFERENCE 

Violet  and  Fisher 

270 

1 

Lyons  <  Ihir.,  Nov.,  1910. 

Kohler 

7,780 

12 

Brit.  Med.  Jour.,  Jan.,  1910. 

Hahm 

708 

8 

Brit.  Med.  Jour.,  Jan.,  1910. 

Helm 

1,419 

0 

P.cit.  /..  klin.  Chir.,  Lxxi-v. 

Barker 

2,354 

O 

Anesthesia,  Gwathmey,  1914. 

Grwathmey 

521 

0 

Jour.  Am.  Med.  Assn.,  Nov.,  1912. 

Bainbridge 

1,065 

1 

Jour.  Am.  Med.  Assn.,  Nov.,  1912. 

Allen 

320 

0 

Jour  Am.  Med.  Assn.,  Nov.,   1912. 

Babeock 

5,000 

11 

Am.  Jour.  Obst.,  Nov.,  1914. 

Gellhorn 

63 

0 

Jour.   Am.  Med.  Assn.,  June,  1914. 

Merenes 

169 

0 

Ann.   Surg.,  Dec,  1913. 

This  series  of  cases  gives  a  mortality  rate  of  1  in  515.  Other  in- 
vestigators report  cases  as  follows:  Strauss,  22,717  cases  with  46 
deaths,  Chiene,  12,000  cases  with  36  deaths,  the  average  mortality 
heing  1  in  623.23 

VI.     Under  Scopolamine 


REPORTER 

CASKS 

DEATHS 

reference 

Maass 

1,499 

11 

Therap.  Monatsehr.,  Aug.,  190."). 

Roith 

1,000 

L8 

Miiuchen.  med.  Wchnschr.,  1905. 

Muhsam 

28,809 

5 

Med.  Klin.,  June,  1912. 

Viron    and    Mori  1 

2,000 

25 

Progres.   med.,  xxii,   1906. 

Beach 

L,000 

0 

Am.  Jour.  Obst.,  May,   1915. 

Etongy 

2,000 

0 

Am.  Jour.   Obst.,   May,    L915. 

The  average  mortality  in  1liis  series  was  1  in  666  cases.  II.  ( '. 
Wood,  Jr..  lias  collected  1,988  cases  of  scopolamine  anesthesia  from 
the  literature  and  reports  a  mortality  rale  of  1   in  221. 

VII.  Under  Local  Anesthesia.  No  accurate  list  of  cases  could 
be  obtained,  but  a  certain  number  of  fatalities  have  been  reported 
by  such  men  as  Proskauer,24  Lichtenstein,25  Miller,26  Grwathmey,27 
and  6  case's  by  Plemming.28 

VIII.  Under  Other  .Methods.  Death  from  anesthesia  is  also  met 
with  when  oilier  methods  of  administration  arc  employed.  Pikin29 
reports  12  cases  of  intravenous  anesthesia  with  1  death.  Homans 
and  Hassler  report  1  death  out  of  350  eases.*1  Woolsey  reports  5 
deaths  from  intratracheal  anesthesia,33  while  Robinson  reports  7 
deaths  out  of  1402  cases.  -  The  following  men  reporl  deal  lis  from 
rectal  anesthesia:  Weir  l.;;  Baum  2.:;1  Carson  2.  "  Cunningham  1.'" 

In  regard  to  postoperative  complications  referable  to  anesthetics. 
Homans37  divides  these  into  three  groups. 

1.  Complications  which  depend  directly  upon  the  anesthetic  and 
result  from  inhaling  or  aspirating  infected  material  into  the  lungs. 

2.  A  condition  of  hypostatic  pneumonia  due  to  enfeebled  circula- 
tion and  failure  to  keep  the  lungs  (dear. 

3.  Emboli. 


POSTOPERATIVE    MORTALITY  669 

It  lias  been  shown  by  Graham38  that  the  "reduction  of  the  phago- 
cytic power  of  the  blood  after  an  ordinary  ether  anesthesia  con- 
tinued in  different  experiments  over  periods  of  2  days  to  7  weeks 
in  duration."  We  are  thus  shown  how  ether  will  lower  the  natural 
resistance  of  the  body  and  make  the  patient  more  liable  to  infection. 
With  regard  to  the  effects  of  ether  on  the  lung  tissue  itself  Chap- 
man39 states  that  ether  has  an  irritating  effect  on  the  lung  tissue 
with  subsequent  swelling  of  the  alveoli  and  congestion,  and  in  some 
cases  even  hemorrhage  which  is  proportional  to  the  amount  of  ether 
given.  From  these  two  observations  one  can  easily  see  how  patients 
may  readily  contract  such  complications  as  aspiration  or  hypostatic 
pneumonia.  Miller40  states  that  ether  lowers  the  coagulation  time 
of  the  blood  which  he  thinks  may  play  an  important  part  in  the 
production  of  postoperative  emboli  or  thrombi.  In  regard  to  the 
fatalities  due  to  lung  complications  Homans41  reports  a  collected 
series  of  15,043  laparotomies  with  a  death  rate  of  4.4  per  cent;  from 
Boston  hospitals  he  reports  from  a  collection  of  3,089  laparotomies 
with  a  mortality  of  0.4  per  cent  due  to  these  same  complications. 
Out  of  a  collection  of  6.825  operations  Beekman42  reports  lung 
complications  in  87  with  no  deaths. 

Considering  next  the  heading,  operative  mortality,  it  might  be 
well  to  consider,  briefly,  the  evolution  of  antiseptic  surgery  and  its 
bearing  on  the  mortality  of  operations.  Lucas  Championniere  has 
been  cpioted  as  saying  that  there  were  only  two  periods  in  surgery — 
that  before  Lister  and  that  after  Lister.  With  the  advent  of  the 
nineteenth  century,  surgery  was  revolutionized.  The  cause  of  pu- 
trefaction of  animal  and  vegetable  material,  was  being  investigated 
and  many  theories  were  given  only  to  be  cast  aside,  until  Pasteur 
made  his  famous  studies  on  the  fermentation  of  alcoholic  beverages. 
He  showed  that  not  only  the  fermentation  of  beer  and  wine  was  due  to 
living  organisms,  but  that  all  putrefactions  were  due  to  the  same 
cause.  In  1845  a  step  further  in  the  support  of  the  germ  theory  of 
disease  was  made  by  Semmelweiss  who  discovered  that  puerperal 
fever  in  the  General  Hospital  at  Vienna  was  due  to  infection  borne 
from  the  dissecting  room  on  the  hands  of  the  students,  and,  by 
insisting  on  hand  cleansing  with  chlorinated  lime  water  he  reduced 
a  mortality  rate  of  12.24  per  cent  to  1.27  per  cent.  In  1862  Pas- 
teur's experiments  lead  him  to  the  conclusion  that  suppuration  was 
but  a  fermentation  of  flesh  and  that  this  might  be  prevented  by 
destroying  the  germs  that  caused  it  or  by  preventing  their  entrance. 
To  this  end  he  urged  the  use  of  boric  acid  for  surgical  purposes. 
In  1878  he  advocated  the  use  of  bandages  and  sponges  which  had 


670  AFTER-TREATMENT   OF    SURGICAL   PATIENTS 

been  previously  heated  to  a  temperature  between  130°  C.  and 
150°  C.  and  water  which  had  been  previously  heated  to  110°  C.  or 
120°  C.  Up  to  this  time  no  adequate  surgical  dressing  had  been  in- 
troduced, though  in  1854  the  use  of  carbolic  acid  was  made  by 
Lemaire  of  Paris,  and  in  1855  it  was  first  employed  at  St.  Mary's 
Hospital  in  London. 

The  great  values  of  these  discoveries  as  applied  to  surgery  were 
left  to  be  demonstrated  by  Lister.  When  Lister  entered  the  Uni- 
versity of  Glasgow  as  Professor  of  Surgery  in  1860,  tetanus,  ery- 
sipelas, septicemia,  pyemia  and  hospital  gangrene  were  scarcely 
absent  from  the  wards.  There  was  no  knowledge  of  their  cause  or 
any  means  to  prevent  them.  Lister  then  insisted  upon  scrupulous 
cleanliness  in  the  wards,  frequent  washing  of  the  hands  of  all  at- 
tendants either  at  operations  or  at  wound  dressings,  and  frequent 
changing  of  the  dressings  of  suppurating  wounds.  To  overcome  the 
decomposition  of  the  injured  part  Lister  advised  the  use  of  carbolic 
acid  in  the  dressing  so  as  "to  destroy  the  life  of  the  floating  par- 
ticles" (microbes).  He  also  observed  that  dead  tissue  when  pro- 
tected from  external  influences  was  absorbed.  This  led  to  the  idea 
of  catgut  ligatures.  It  is  not  necessary  to  chronicle  every  step  in 
the  advance  of  asepsis,  but  suffice  it  to  say  that  by  this  time  opera- 
tions were  performed  with  success  which  formerly  could  have  ended 
only  in  failure.  In  1877  Lister  still  employed  carbolized  gauze,  car- 
bolic spray,  and  oiled  silk  but  was  ever  on  the  lookout  for  improve- 
ments, and  when  bichloride  of  mercury  was  proved  to  be  more 
powerful  than  carbolic  acid,  he  experimented  with  it  and  suggested 
the  gauze  dressing  impregnated  with  double  cyanide  of  mercury 
and  zinc  which  is  still  used  by  many.  Ultimately  when  the  carbolic 
spray  was  found  inadequate  to  destroy  bacteria  in  the  dust.  Lister 
abandoned  it.  but  nevertheless  paved  the  way  for  our  modern 
methods  of  surgery.  Today  figures  from  the  London  Hospital  show 
that  98  per  cent  of  operative  wounds  heal  by  tirst  intention,  whereas, 
50  years  ago  80  per  cent  were  attacked  by  hospital  gangrene.43 

The  following  mortality  lists  of  various  operations  are  made 
from  a  variety  of  sources,  but  represent  those  from  reliable  hos- 
pitals or  operators.  Not  every  operation  practiced  is  tabulated,  but 
only  those  which  are  considered  worthy  of  mortality  figures,  either 
on  account  of  their  severity  or  from  their  common  occurrence. 

A.  Alimentary  System.44 
I.  Lymph-adenoid : 

Tonsillectomies  ami  adenoidectomies ;   ~<7  \  cases,  2  deaths. 
Oclisner  reiiorts  593  cases  with  no  deaths.4^ 


POSTOPERATIVE    MORTALITY  671 

II.  Esophagus : 

Gastrostomies  for  carcinoma;  13  cases,  8  deaths.  These  deaths  were 
due  to  the  malignancy  of  the  disease. 

III.  Stomach,  Pyloris  and  Duodenum. 

Gastroenterostomies  for  neoplasms:  70  cases,  5' deaths.  Ulcers,  either 
excisions  or  resections:  67  cases,  1  death. 

Mayo,46  out  of  1000  cases  of  ulcer,  irrespective  of  operations,  types 
or  cases,  reports  a  mortality  of  2.4%. 

In  malignancy  of  the  stomach,  gastrostomy  being  done,  Mayo4? 
reports  an  immediate  mortality  of  25  to  55%. 

In  the  same  operation  and  cause,  McCosh  reports  a  mortality  of 
30%;  Robson,  38.3%;   Czerny,  38.5%;  Mukulicz,  32%. 

IV.  Liver  and  Biliary  Tract: 

Choleeystostomies  —  choledochotomies  —  cholecystectomies,  etc. :  210 
cases  with  14  deaths. 

The  Mayo  brothers  report  the  following  series  of  operations  for  a 
period  of  ten  years  :4S 

Removal  of  benign  tumors,  311  cases,  8  deaths. 
Removal  of  malignant  tumors,  17  cases,  3  deaths. 
A  later  report^  of  1500  cases  operated  upon  shows  66  deaths  or  a 
mortality   of   4.43%.      Of   the   first    1000   cases   845   were   choleeystos- 
tomies with  a  mortality  of  2.1% ;   of  the  last  500  the  mortality  for 
the  same  operation   was   1.47%.      The  mortality  of   cholecystectomies 
for  the  first  1000  cases  was  3.13%  and  for  the  last  500  cases  1.62%. 
Their  figures  for  operations  on  the  common  duet  are  as  follows: 
Stones — partial    obstruction,    105    cases,    3    deaths,   mortality   2.9%. 
complete  obstruction,  29  cases,  10  deaths,  mortality  34%. 
with  infection,  61  cases,  10  deaths,  mortality  16%. 
malignancy,  12  cases,  4  deaths,  mortality  33%. 
Ochsner^s    reports    124    cholecystectomies    with    7    deaths;    and    39 
choleeystostomies  with  2  deaths. 
V.  Intestines. 

Appendectomies,  625  cases,  20  deaths. 
Ochsner  reports  655  cases  with  3  deaths. *s 
Hernias — Epigastric,  12  cases,  no  deaths. 
Femoral,  43  cases,  no  deaths. 
Ventral,  35  cases,  no  deaths. 
Umbilical,  23  cases,  5  deaths. 
Inguinal,  506  cases,  4  deaths. 
Ochsnei'45  reports — Femoral,   7  cases,   2  deaths;   Inguinal,   68  cases, 
no  deaths;  Ventral,  15  cases,  no  deaths;  Umbilical,  4  cases,  no  deaths. 
VI.  Rectum  and  Anns : 

Hemorrhoids,  ligation  and  excision  by  various  methods,  186  cases 
with  no  deaths. 

Fistula  and  Fissure,  43  cases  and  no  deaths. 
Resection  of  rectum,  20  cases,  2  deaths. 
Ochsner-ts — Hemorrhoids,  87  cases,  no  deaths. 

Obstruction,  17  cases,  9  deaths,  operation  late. 
Resections   and   colostomies   for   carcinoma,    12    cases,    2 
deaths. 


672  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

B.  Vascular  System:** 

I.  Varicose  veins  and  ulcers,  excision,  164  oases  and  1  death. 

C.  Ductless  Glands. it 

I.  Hypophysis — transsphenoidal,  sellar  decompressions,  etc.,  7-1  oases  and  2 
death-. 
II.   Thyroid. 

Partial   Thyroidectomy : 

Adenoma,  cysts,  etc.  25  rases,  no  deaths. 
Colloid.    -  •!  deaths. 

Hyperthyroidism,  29  cases,  1  death. 
Dysthyroidism,  5  cases,  no  deaths. 
Oehsner  reports  128  cases  with  4  deaths. 

Kocher   reports    11    deaths   from    partial   thyroidectomy    for   benign 
ths  from  v7<>  cases  or  a  mortality  of  a  little  more  than  1%.     His 
later  mortality  figure  is  .",  out  of  every   1000  cas< 

D.  Xervous  System:'** 

I.  skull:    decompressions,    craniotomies,    etc.,    for   tumors,   trauma,   hemor- 
rhag  -  s,   7:;  deaths. 

K.  Reproductive  System:** 
I.  B 

Removal  for  benignancy,  29  cases,  no  deaths. 
Oehsner,  same,  32  cases,  no  deaths.*5 
Removal  for  malignancy,  61   cases,  1  death. 
Oehsner,  same,  •"•!  cases,  no  deaths. 
IL   Uterus: 

Hysterectomies,  al  dominal  and  combined  routes.  83  cases,  '2  deaths. 
Mayo  reports  504  myomectomies  from  January  1.  1891,  to  September 
1.  1916,  with    1   deaths  or  a  mortality  of  0.8 
Ochsner's  figures  are  as  follows: 
Hysterectomies  and  Panhysterectomies  -.  4  death-. 

III.  Uterine  Appendages: 

Salpingectomies,  salpingo-oophorectomies,    119  cases,    1   deaths. 

Oehsner1" —on    salpinx.   41    eases.    1    death. 
on    o\  ary.    1  I    cases,   2   deaths. 
IV.  Prostate: 

Prostatectomies  or  Prostatomies,  61  cases,  5  deaths. 
Ochsner,*s  same  operation,  25  cas  s,  2  deaths. 
P.  Respiratory  System.** 
I.  Pharynx: 

Tracheotomy,  2  cases,  no  deaths. 

II.  Lungs   and    Pleura-: 

Tho] :  36  deaths. 

Oehsner.'"  same  operations,  -".ii  cases,   I  deaths. 

G.  Skeletal: 

1.  Osteomyelitis,  acute  and   ehronic,    14(  2   deaths:    Tuberculous,   x 

-.  no  deaths;   Actinomycotic,  2  eases,  m,  deaths. 


POSTOPERATIVE    MORTALITY  673 

H.  Urinary  System:44 
I.  Kidney: 

Nephrectomies,  21  cases,  no  deaths. 
Nephrotomies,   81  cases,  5  deaths. 
II.  Ureter: 

Ureterotomies,  17  cases,  no  deaths. 

III.  Bladder: 

Supra-pubic  cystotomies,  29  cases,  1  death. 
Ochsner,'4f>,  25  cases,  no  deaths. 

We  will  not  attempt  to  summarize  or  lay  down  any  conclusions 
regarding-  postoperative  mortality  as  discussed  in  this  chapter,  since 
in  doing  so  we  would  only  make  a  repetition  of  the  figures  already 
given.  The  tabulated  figures  themselves  serve  the  best  deductions 
and  conclusions  that  we  can  offer. 

Full  credit  is  due  B.  L.  Adelsberger  for  having  abstracted  all  the 
literature  to  which  reference  is  made  in  this  chapter. 


Bibliography 

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Analgesia,  i,  containing  Miller's  article  "Mortality  Under  Anesthetics,"  from 
which  the  figures  in  Sections  I  to  VIII,  inclusive,  of  this  article  were  taken. 

iSkeel:     Mortality  of  Abdominal  Surgery,  Jour.  Mich.  State  Med.  Soc,  Febru- 
ary, 1915. 

2British  Med.  Jour.,  1889. 

sLevy:     Cardiac  Fibrillation  and  Chloroform  Syncope,  Am.  Year  Book  of  Anes- 
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4Muhsam:     Med.  Klin.,  1912. 

sRoberts:     Surg.,  Gynec.  and  Obst.,  August,  1911. 

e  Williams:     Clinical  Jour.,  December,  1908. 

^Henderson :     Surg.,  Gynec.  and  Obst.,  August,  1911. 

sMiller:      Mortality    under    Anesthetics,    Am.    Year    Book    of    Anesthetics    and 
Analgesia,  i. 

QGraham:     Researches  on  Late  Chloroform  Poisoning,  Am.  Year  Book  of  Anes- 
thetics and  Analgesia,  i. 
ioHewitt:     Anesthetics,  New  York,  1912,  Macmillan  Co. 
nlbid.,  138. 
izlbid.,  138. 
islbid.,  139. 

i4Eisendrath:     Am.  Med.,  November,  1902. 
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iTjour.  Am.  Med.  Assn.,  October,  1913. 
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2iBuxton:     Anesthetics,  Philadelphia,  1900,  P.  Blakiston's  Son  &  Co. 
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24Proskauer :     Therap.  d.  Gegenw.,  December,  1913,  liv,  No.  12. 
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674  AFTER-TREATMENT    OF    SURGICAL   PATIENTS 

2'Gwatlnney:     Anesthesia,  New  York,  1014,  D.  Appleton  &  Co. 
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apman:     Ann.     Surg.,  1904. 
i"Miller:8 
nMiller:8 

42Beekman:     Surg.,  Gynec.  and  Obst.,  May,  1914. 
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"Peter  Bent  Brigham  Hospital  Reports,  1913-1917,  inclusive. 
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